Osteopathy and Osteopathic Medicine
A Global View of Practice, Patients, Education and the Contribution to Healthcare Delivery
FOREWORD
The World Health Organization has set out three key objectives This report from the Osteopathic International Alliance is the in its Traditional Medicine Strategy 2014-2023: culmination of several years work on behalf of the international profession. A profession that now has a global presence, being l To build the knowledge base for active management of practised on every continent except Antarctica. traditional and complementary medicine through appropriate national policies After the publication of the World Health Organization Benchmarks for Training in Osteopathy in 2010 the OIA Board l To strengthen quality assurance, safety, proper use and was given a strong mandate to demonstrate the profession’s effectiveness of traditional and complementary medicine by international contribution to healthcare delivery. regulating products, practices and practitioners All member organisations have contributed to this report from l To promote universal health coverage by integrating traditional various sectors of the profession including national professional and complementary medicine services appropriately into associations, regulators, accreditation authorities and educational national health service delivery and self-healthcare. institutions.
This report from the Osteopathic International Alliance is an The result is an affirmation of the success of the coming together important achievement for the osteopathic profession in collating of both streams of the profession, from both regulated and and reporting baseline data regarding the state of the profession unregulated countries, under the unifying umbrella of the OIA. worldwide. It provides useful information for policy makers to consider the contribution to the healthcare sector made by Particular thanks goes to: the osteopathic profession; the development in education and regulation standards; and the efforts on safety and quality of Mr Clive Standen, Past Chair OIA Board, NZ service delivery. The report is also helpful in the implementation Dr John Heard, Vice President Research, AT Still University, USA of the WHO Traditional Medicine Strategy 2014-2023 and the Dr Johannes Meyer, Past Chair OIA Board, Germany WHO Benchmarks for Training in Osteopathy. Dr Jane Carreiro, Chair OIA Editorial Committee, USA Mr Tim Walker, OIA Editorial Committee, UK Dr Zhang Qi Mr Simon Fielding, OIA Editorial Committee, UK Coordinator of Traditional and Complementary Ms Teresa Poole, medical and technical author, UK Medicine Programme The National Council for Osteopathic Research, UK World Health Organization Michael Mulholland-Licht Chair, OIA Board of Directors
Contents
Summary of key points 2 Areas of specialty practice 42 Time spent on osteopathic manipulative treatment 44 Introduction 6 (OMT) Purpose and target audience 6 Osteopathic techniques used in treatment 45 the role of the Osteopathic International Alliance 6 Integrating manipulative therapy with other treatments 48 the World Health Organization and osteopathic practice 7 the relationship between osteopathic healthcare and 49 structure of this report 7 national health systems Formal integration 49 Prior consultations with other healthcare professions 51 Chapter 1: The concept, history and spread of 8 1 osteopathic healthcare Referrals by osteopaths to other health services 52 What is osteopathic healthcare? 9 profession demographics 53 The range of manual techniques 10 Age distribution 53 the origins and dissemination of osteopathic practice 11 Gender split of practitioners 54 Foundation of the first osteopathic schools 11 The spread to Europe and beyond 11 Chapter 3: Models of education and regulation 56 current models and scope of practice 13 Osteopathic education and course accreditation 58 Osteopathic physicians 13 Qualifications of an osteopathic physician 59 Osteopaths 14 Qualifications of an osteopath 59 The World Health Organization’s 2009 resolution 15 Standardisation and accreditation in osteopathic 61 education Chapter 2: Practitioners, patients and the scale of 16 Recognition, regulation and registration 62 osteopathic practice Recognition and regulation of osteopathic physicians 62 the size and growth of the profession 18 Recognition and regulation of osteopaths 63 Number of practitioners 18 Establishing common practice standards in Europe 66 The osteopathic student population 22 scope of practice 67 Entry level qualifications 23 Maintaining standards and fitness to practise 68 Osteopathic patient care 25 Inter-country recognition of osteopathic qualifications 70 Age and gender of patients 25 Patients’ reasons for seeking osteopathic care 29 Chapter 4: Efficacy, safety and cost-effectiveness 72 Patient pathways to osteopathic care 30 clinical guidelines on low back pain 74 Patients’ general health complaints when seeking 32 evidence of the outcomes of osteopathic techniques 75 osteopathic treatment Musculoskeletal pain 75 Physical location of presenting health complaints 33 Back pain 75 Osteopathic care of children 34 Headache and neck pain 77 How much is spent? 38 Miscellaneous 79 Who pays, and does health insurance cover 38 safety of osteopathic practice 81 osteopathic healthcare? cost-effectiveness of osteopathic practice 83 A profile of osteopathic practice 40 development of research 84 Practice setting and time worked 40 References 85 Length of patient consultations 41
Summary of key points
Once considered complementary The concepts, history Practitioners, patients and or alternative, osteopathic and spread of osteopathic the scale of osteopathic medicine and osteopathy now healthcare (Chapter 1) practice (Chapter 2) make a global contribution l Osteopathic healthcare is based on Practitioners to patient-centred, evidence- the principle that the structure and l The OIA 2013 survey of 33 countries informed, integrated healthcare. functions of the body are closely identified at least 87,850 osteopathic integrated, and that a person’s physicians worldwide, a 70% increase well-being is dependent upon the over the past decade. The vast 2 neurological, musculoskeletal and majority (82,500) are in the US, visceral structures working in balance where in 2012 osteopathic physicians together. accounted for 7.2% of US physicians.
l The approach was established in 1874 l The survey identified approximately in the US by Andrew Taylor Still; over 43,000 osteopaths worldwide, nearly the first half of the 20th century triple the number a decade ago. The osteopathic practice rapidly spread countries with the largest number globally. are France, Germany, Italy, UK, Australia, Belgium and Canada, which l Osteopathic healthcare is now together accounted for almost 38,000 provided in every continent except practitioners. Antarctica and is practised in more than 50 countries. l The total number of students enrolled at US osteopathic medical schools l Globally, two professional streams has risen from 14,409 in 2006-7 have emerged, largely due to different to 21,741 in 2012-13. The OIA legal and regulatory structures around 2013 survey identified 25 countries the world: osteopathic physicians with osteopathy training schools or (practising osteopathic medicine) are universities: the countries where doctors with full, unlimited medical data were available reported 14,750 practice rights and can specialise enrolled osteopathy students, of in any branch of medical care; whom 10,000 were in France. osteopaths (practising osteopathy) are primary contact health providers with nationally-defined practice rights, and may not for example prescribe pharmaceuticals or perform surgery. Patients l In countries that do not have wide l Several different osteopathic l Osteopathic practitioners treat coverage of private health insurance, techniques are typically used to treat patients of all ages, from birth to very most osteopathic treatment is self- a single patient. These cover rhythmic old age. The OIA 2012 survey found funded by patients. techniques, short precise impulses, one-third of patients were between joint positioning techniques and very 31 and 50 years old. Nearly a quarter Practice characteristics gentle specifically applied pressures. (23.4%) were aged 18 and younger, l The most common work environment including 8.7% below the age of two for both osteopathic physicians and l Osteopathic practitioners commonly years. osteopaths is private practice, with integrate osteopathic techniques with 3 or without partners. According to other healthcare treatments such as l In the OIA 2012 survey, acute, the OIA 2012 survey, about half of all pain medication, standard healthcare sub-acute and chronic conditions osteopathic practitioners work at least and complementary therapies. The were similarly cited by patients as seven hours a day. In both professional OIA 2012 survey found that around their reason for seeking osteopathic streams, part-time working is 39% of the last 10 acute patients were treatment; in addition, approximately common. taking medication for pain in addition one in five patients attended for a to osteopathic treatment, while 42% general osteopathic check-up. l The majority of practitioners work as of the last 10 chronic patients were primary care physicians or generalist doing so. l More than half of patients were osteopaths. In the US, around 60% seeking help for pain. Acute patients of practising osteopathic physicians l Physiotherapy, massage and a range of most commonly presented with work in the primary care specialties complementary medicine techniques problems due to local pain and of family medicine, general internal are commonly provided in addition to restricted motion. For chronic patients medicine, paediatrics, and obstetrics osteopathy, both for acute and chronic their pain was more likely to be over a and gynaecology. Most osteopaths, conditions. According to the OIA larger area. even if they have an area of particular 2012 survey, around 27% of patients interest, treat a wide range of patients had received at least one additional l The range of presenting symptoms is and conditions. treatment. very diverse, but all surveys indicate that musculoskeletal back pain is the l Osteopathic manipulative treatment Relationship with the wider most common condition among (OMT) is a core activity for both healthcare system osteopathic patients. osteopathic physicians and osteopaths. l As well as examples of formal The OIA 2012 survey found that integration of osteopathic healthcare l For both acute and chronic patient more than a quarter of US and EU within national healthcare systems, groups, the lumbar spine, neck, osteopathic physicians spent more osteopaths work constructively in thoracic spine, thorax, and pelvic area than half their work time delivering parallel and in communication with were the most frequent areas with OMT, although almost half said it physicians and other healthcare problems. represented less than 10% of their professionals. work. Among osteopaths, more than 90% spent more than half their time delivering OMT. l The OIA 2012 survey found that a Models of education and l There have been several initiatives majority of patients had attended regulation (Chapter 3) to describe minimum standards for consultations with medical doctors osteopathic education and training, l Recognition, education and regulation or other healthcare providers before of osteopathic practitioners have including the WHO Benchmarks for presenting for osteopathic treatment. developed differently around the Training in Osteopathy in 2010 and, in This was true both for patients world, influenced by the specific Europe, the European Framework for of osteopathic physicians and of cultural, economic, legal and political Standards of Osteopathic Education osteopaths. factors of individual countries. and Training (EFSOET), developed by 4 the Forum for Osteopathic Regulation Profession demographics Education in Europe (FORE). l The osteopathic profession is l Osteopathic education programmes Regulation relatively ‘youthful’. In the US, 58% of exist in more than 25 countries. osteopathic physicians are under the Osteopathic physicians and osteopaths l State licensing of osteopathic age of 45. The 2012 OIA survey found share a core curriculum and core physicians dates back to 1897 in that around one-third of osteopaths competencies, but there are significant the US and licensing of osteopaths were below the age of 40, although differences between the two to 1978 in Australia. Healthcare there is considerable variation professional streams in education, regulators in several other countries between individual countries. clinical competency, and scopes of have deemed it important to establish practice. a legal framework for the practice of l The proportion of female osteopathic healthcare in order to practitioners has increased. In the US, ensure standards for public safety. l All osteopathic physicians are women now account for more than a university graduates holding medical third of all osteopathic physicians and degrees: in the US they study l More countries are now recognising in the under-35 age group women osteopathic medicine, which is fully and regulating osteopathic care. Since outnumber men. The OIA 2012 integrated with medical schools, but 2000 there has been an increase in survey found that 48.7% of responding elsewhere most osteopathic physicians countries introducing compulsory osteopaths were female; men are now are MDs with additional osteopathic osteopathic practitioner registration the minority among osteopaths below qualifications. and/or regulation of practice; there the age of 30, although again there are now at least 15 countries where is considerable variation between osteopathy and/or osteopathic l Across much of Europe, Australia and individual countries. New Zealand, the generally accepted medicine are regulated. norm for training as an osteopath has become a Master’s level qualification. l There is still no statutory regulatory In some countries the equivalent framework for osteopathy in of a Bachelor’s degree remains the the majority of countries where accepted norm or post-professional osteopaths practise. training is accepted. l The permitted scope of practice Efficacy, safety and cost- of an osteopathic physician is set effectiveness (Chapter 4) Use of terminology by the relevant country’s licensing l A body of evidence on manual Where relevant, this report and regulatory systems for doctors, techniques exists, in the form of distinguishes between ‘osteopathy’ and including any specific requirements systematic reviews and randomised ‘osteopathic medicine’, and between for working as a specialist. In countries controlled trials, showing the the two professional ‘streams’: where there is regulation, osteopaths’ effectiveness of manual therapy using osteopaths and osteopathic physicians. practice rights will be nationally manipulation for low back pain. Terms such as ‘osteopathic healthcare’ defined. However, for osteopaths and ‘osteopathic practitioner’ 5 in countries that do not recognise l In Australia, Europe, New Zealand are used more generally to cover or regulate the profession, scope of and the US, clinical guidelines for healthcare practice and practitioners practice is often less clear cut. the treatment of low back pain incorporating osteopathic principles. recommend osteopathic techniques l The osteopathic profession is such as spinal manipulation. Osteopathic physicians are referred to committed to monitoring and in this report as DOs (for Doctor of maintaining standards of practice l Robust scientific research into Osteopathic Medicine) and their and ethics. In countries with the efficacy of other osteopathic non-osteopathic counterparts as MDs compulsory licensing or registration, techniques has been limited, and in (for Doctor of Medicine). Specific osteopathic practitioners are usually many areas remains inconclusive. degree qualification titles vary between required periodically to renew their countries; for instance, the DO title licence or registration. In countries l The osteopathic profession is can be used more widely in some where osteopathy is not regulated, committed to evidence-based practice countries for a diploma in osteopathy. professional associations usually work and over the past decade there to maintain standards and to establish has been an expansion in research accepted thresholds of entry into the activity on the outcomes and efficacy profession. of techniques used by osteopathic practitioners. Introduction
Growing numbers of patients are Purpose and target audience The role of the Osteopathic seeking access to osteopathic This report describes the current state International Alliance healthcare and more countries are of osteopathy and osteopathic medicine This project is an initiative of the now recognising the osteopathic globally and how these disciplines interact Osteopathic International Alliance approach within their regulatory with national health systems across a (OIA), the international organisation and national health systems. This range of countries. It uses the most robust representing national and international reflects the geographical expansion data available, while acknowledging gaps osteopathic bodies and their osteopath of osteopathy and osteopathic in the current evidence. The report and osteopathic physician members medicine over the past 30 years. 6 addresses some key questions: Who are worldwide. One of the OIA’s main goals Osteopathic healthcare is now the practitioners, and is the composition is to ‘collect and disseminate accurate and provided in every continent except of the profession changing? How many targeted information about the state of Antarctica and is practised in people seek osteopathic treatment and the osteopathic profession worldwide’.1 more than 50 countries.* Yet, to for what main conditions? Who pays? In March 2012, the OIA published Stage date, the role of the osteopathic To what extent is osteopathic practice One of its Status Report on Osteopathy,2 profession has not been effectively integrated within national health systems? which focused on the principles and communicated to a wider And how do the various regulatory and practice of osteopathy and osteopathic audience; including how and where accreditation systems for osteopathy medicine, core competencies, statutory osteopathic treatment is used by and osteopathic medicine function around systems and educational standards. A patients within the overall delivery the world? survey (the OIA 2012 survey†) carried of healthcare worldwide. out for Stage Two produced an audit of The target audience includes: national current osteopathic practice, based on and international policymakers; health a global ‘snapshot’ of patients; the data ministers; government departments; non- from this survey have been used in the governmental organisations; educators preparation of this report. and students; health media; and interested members of the public. The report aims Osteopathy and Osteopathic Medicine: A to inform readers about the current scale Global View of Practice, Patients, Education of osteopathic practice and how patients and the Contribution to Healthcare Delivery served by national healthcare systems also complements the OIA’s existing research use osteopathic treatment. by drawing together data from around the world to describe the extent and role of osteopathic practice. While some national studies exist, this is the first such analysis incorporating an international perspective.
* Based on data collected by the Osteopathic International Alliance and the UK’s General Osteopathic Council. † See Chapter 2 for details of this survey. The World Health l Practitioners, patients and the scale Organization and of osteopathic practice (Chapter 2) osteopathic practice sets out the best available data and information on those who currently This publication originally grew out of practise, study, receive and pay for discussions with the WHO about the osteopathic healthcare; looks at need for a wider understanding of the patient and practice characteristics; global ‘footprint’ of osteopathy and and assesses the integration/non- osteopathic medicine. In 2010, publication integration within national healthcare of the WHO’s Benchmarks for Training in 7 systems. Osteopathy3 marked an important step towards the worldwide acceptance and l Models of education and regulation integration of the osteopathic profession (Chapter 3) describes the different into national systems of healthcare. models worldwide for osteopathic Through this OIA report, the osteopathic education; sets out the variations profession hopes to contribute to the between countries in the recognition WHO’s policy development work. and regulation of osteopathic practice; and reviews how the profession Structure of this report maintains standards and fitness to practise. This report covers four main subject areas: l Efficacy, safety and cost-effectiveness (Chapter 4) summarises the key l The concept, history and spread of research findings in these areas. osteopathic healthcare (Chapter 1) provides a short introduction to osteopathic healthcare; outlines the evolution and growth of the discipline worldwide; and describes the two professional streams that have emerged. Chapter 1 The concept, history and spread of osteopathic healthcare
KEY POINTS
l Osteopathic healthcare is based on the principle that the structure and functions of the body are closely integrated, and that a person’s 8 well-being is dependent upon the neurological, musculoskeletal and visceral structures working in balance together.
l the approach was established in 1874 in the US by Andrew Taylor Still; over the first half of the 20th century osteopathic practice rapidly spread globally.
l Osteopathic healthcare is now provided in every continent except Antarctica and is practised in more than 50 countries.
l Globally, two professional streams have emerged, largely due to different legal and regulatory structures around the world: osteopathic physicians (practising osteopathic medicine) are doctors with full, unlimited medical practice rights and can specialise in any branch of medical care; osteopaths (practising osteopathy) are primary contact health providers with nationally-defined practice rights, and do not for example prescribe pharmaceuticals or perform surgery. What is osteopathic healthcare?
Osteopathic healthcare offers a system Central to the osteopathic approach is of assessment, diagnosis and management a range of ‘hands-on’ manual techniques Box 1.1 THE PRINCIPLES OF that can be applied across a wide range for assessment, diagnosis and treatment. OSTEOPATHIC CARE of medical conditions. It is based on the These techniques help the practitioner Overall, the philosophy of osteopathic principle that the structure and functions to identify and treat certain health care incorporates three key principles in of the body are closely integrated, and conditions, including musculoskeletal the management of patients, prevention that a person’s well-being requires the structural problems that, according to the of disorders and promotion of well-being: neurological, musculoskeletal, circulatory osteopathic view, can influence the body’s physiology, including the nervous system, and visceral structures to work in balance 9 together. circulation and internal organs. • The human being is a dynamic unit of function, whose state of health Osteopathic practice aims to restore The osteopathic approach incorporates is influenced by the body, mind and (and maintain) a person’s body to its current medical and scientific knowledge spirit. overall natural state of well-being. This when applying these osteopathic principles homeostasis is seen as promoting the to patient care. Scientific review and • Structure and function are body’s ability to heal and regulate itself evidence-informed outcomes have a high interrelated at all levels. (Box 1.1). priority in patient treatment and case management. • The body possesses self-regulatory Osteopathic practitioners thus assess mechanisms and is naturally self- and treat the ‘whole person’, rather Osteopathic manipulative treatment is healing. than just focussing on specific symptoms most widely known for treatment of (Source: Osteopathic International Alliance or illnesses. Patients presenting with a musculoskeletal disorders such as back (2012) History and Current Context of the particular condition are given an overall and neck pain, sciatica, sporting injuries Osteopathic Profession, Status Report on structural and functional assessment and postural strain. It is also used to Osteopathy Stage 1. Chicago: OIA.) in line with the osteopathic view that assist in the treatment of functional the primary cause of the disorder may problems such as breathing disorders, be remote from the symptoms. This otitis media, digestive problems and perception of the body as an integrated menstrual disorders. As primary whole means that osteopathic healthcare healthcare practitioners, the osteopathic is often described as ‘person-centred’ profession recognises its responsibility to rather than ‘disease-centred’ in its diagnose and refer patients as appropriate approach to the prevention, diagnosis when the patient’s condition requires and treatment of illness and injury. To an therapeutic intervention that falls outside osteopathic practitioner, for a person to the competence of an osteopathic maintain optimal health, their neurological, practitioner.4 musculoskeletal, circulatory and visceral structures must all be functioning well. The osteopathic profession is distinct from The range of manual Manual techniques may be combined other healthcare professions that utilise techniques with advice on exercise, posture and manual and manipulative techniques, such Osteopathic practitioners use a wide nutrition to aid recovery, promote as physiotherapy and chiropractic, and has variety of therapeutic manual techniques health and prevent symptoms recurring. its own distinctive approach. Osteopathic in the diagnosis and management of Encouraging patients to develop attitudes education, professional associations and disease and the maintenance of health. and lifestyles that do not just fight illness international associations are independent These are based upon a highly developed but also help prevent disease is a core of these other professions, an important sense of touch (palpation), physical aspect of the osteopathic philosophy. The biopsychosocial approach of osteopathic 10 point in many countries where osteopathic manipulation, soft tissue treatment and practice is developing. The extent to stretching. Such techniques are used to: healthcare encompasses more than the which osteopathic healthcare does, or assess, evaluate and diagnose; increase the whole physical body: an individual’s work, does not, share any characteristics with mobility of joints; relieve muscle tension; emotional, family, beliefs and cultural other healthcare disciplines is outside the enhance blood and optimise nerve supply background are also considered and taken scope of this report. to tissues; and to help the body’s own self- into account by the practitioner. regulating and self-healing mechanisms.
The different elements of osteopathic manipulative treatment (OMT) include short precise impulses, rhythmic mobilising and stretching techniques, joint positioning techniques and very gentle specifically applied pressures. The treatments are designed to strengthen unstable joints and address areas of tissue strain, stress or dysfunction that may impede normal nerve function, circulation and biochemical mechanisms.
The origins and dissemination of osteopathic practice
Within the Western tradition, written In search of a more accepting languages, who had emigrated to America descriptions of manipulation and the environment, he moved to Missouri, in 1892. In 1897, Littlejohn joined Still at treatment of the musculoskeletal system eventually settling in Kirksville in 1875. His ASO in Kirksville, and subsequently moved can be traced as far back as Hippocrates reputation grew and by the mid-1880s he to Chicago in 1900 to found the American (c460-c370 BC) and for centuries there had gained a large patient following.6 College of Osteopathic Medicine. By 1902 have been individuals – historically called Littlejohn had also qualified as a medical ‘bone-setters’ – skilled in the manipulation physician. of joints. Andrew Taylor Still, founder of Foundation of the first osteopathic schools the osteopathic approach, was born in Still died in 1917, by which time there 11 1828 in the American state of Virginia, In 1892, Still founded the American were around 5,0009 osteopathic and took up medicine as an apprentice School of Osteopathy (ASO) in Kirksville, practitioners in the US and many others to his father, learning the rudimentary in a modest two-room building. The had spread across the globe. medical techniques of the day. In 1864, first graduates started to emerge two around the time he returned home from years later and in 18967 the State of the Civil War, three of Still’s children Vermont became the first to recognise the The spread to Europe and died during a spinal meningitis epidemic, profession of osteopathy. Between 1896- beyond followed by a daughter from pneumonia. 9, 13 osteopathic colleges were opened Over the first half of the 20th century, These personal tragedies, together in the US (some by ASO students setting the ASO’s alumni played key roles in with his early medical work and army up in competition with the ASO) and in the development and spread of the experiences, had led Still increasingly to 1897 the American Association for the new osteopathic discipline. One of Still’s question the efficacy of existing 19th Advancement of Osteopathy (later known students, William Garner Sutherland, century medical practice. as the American Osteopathic Association) extended Still’s approach to the was founded. skull, founding the concept of cranial Still’s interest in machines and anatomy osteopathy. His text, The Cranial Bowl, gradually convinced him that using manual In 1897 Missouri introduced state licensing was published in 1939 after four decades techniques to correct malfunctions of covering the ASO and its graduates as of investigations. the body’s musculoskeletal system would independent physicians and surgeons. promote healing and maintain health. This required changes to the curriculum The expansion of the osteopathic In 1874, he first articulated this new and osteopathy began to evolve from approach into mainland Europe and approach, which he subsequently called the ‘evangelical osteopathy’ of Still to a beyond was often spearheaded by former ‘osteopathy’ – from the Greek osteon more science-based discipline. By 1911, ASO pupils, their students and graduates (bone) and pathos (suffering, disease, for instance, the ASO had incorporated of other US osteopathic colleges. A feeling). Still believed osteopathy was vaccines, serum therapy and antitoxins into list of overseas students from Kirksville an independent system of medicine the bacteriology course.8 compiled by the Still National Museum that could be applied to all conditions, shows that by 1913, graduating students and initially met with considerable local A key figure in the development and were enrolled from countries as far opposition to his ideas, including from his spread of the osteopathic approach flung as Mexico, Germany, Persia, Syria, own family.5 was John Martin Littlejohn, a Scotsman New Zealand, Bermuda, Norway and educated in divinity, law and oriental Denmark.10 Key dates in the early history of osteopathic healthcare
1874: Modern ‘osteopathy’ founded 1900: John Martin Littlejohn opens the 1917: British School of Osteopathy by Andrew Taylor Still American College of Osteopathic opens Medicine in Chicago 1892: Still opens of the American 1930s: Osteopathic practice had School of Osteopathy (ASO) 1909: Osteopathic healthcare spread into mainland Europe in Kirksville, Missouri introduced in Australia and Australasia
1897: Missouri introduces 1913: Littlejohn returns to the UK state licensing
The return of these international students In France, Dr W.J. Douglas, a graduate Further proliferation of the osteopathic to their home countries provided channels from the Los Angeles College of approach was also seen in Switzerland for osteopathic healthcare to gain a Physicians and Surgeons, was in 1936 (under the name of Etiopathy) Belgium, presence outside the US, albeit initially on reported as working in Paris.14 Dr Robert Italy, Spain and Portugal. In Europe a small scale. Lavezzari, who had been taught by one generally (as in France), many of of Still’s pupils, went to Paris in 1936 those who initially studied osteopathic In the UK, the first person to introduce and in 1949 published “Une nouvelle healthcare had a first training in the osteopathic approach was Littlejohn, méthode clinique et thérapeutique: physiotherapy and could avoid legal and 12 through his annual lectures in London l’ostéopathie”. And in 1951, the recognition problems by using osteopathic from 1898 to 1900.11 From then physiotherapist Paul Gény, founded techniques within their existing practice. on, American-trained osteopathic l’École Française d’Ostéopathie where practitioners came to work in England, French-speaking physiotherapists could Worldwide, from the early 20th century, Scotland and Ireland and established a train.15 For legal reasons, the college the discipline had also reached countries market for their skills. In 1913, Littlejohn transferred to the UK in 1965, where including Japan, Israel, Russia, South returned to live in England and in 1917 it eventually evolved into the European Africa, Singapore and Brazil. In many formally opened the British School of School of Osteopathy (ESO).16 The ESO places osteopathic practice achieved only Osteopathy (BSO) in London, the first also helped to initiate academic links in a toe-hold over several decades due to training centre for osteopathic healthcare countries including Belgium, Austria and lack of recognition and/or restrictions to in Europe.12 Russia, and ran courses in Guadeloupe practise. Nevertheless, by the middle of and Ile de la Réunion for French-speaking the 20th century, osteopathic healthcare On the other side of the world, physiotherapists.17 In Germany, Mathilda had established a global presence from osteopathic healthcare was introduced Brunck, who had graduated from Kirksville which it could build. Over the second half in Australia in 1909, with at least three in 1911, was by 1936 practising at of the 20th century, with the introduction American-trained alumni in practice that Charlottenburg.18 of regulatory structures and increased year. Development of the profession recognition within national healthcare focused on the state of Victoria. The US practitioners continued to help to systems, defined models of practice firmly Pax College of Osteopathy (Ballarat) promote the spread of osteopathic established themselves. opened there in 1933, 13 overseas trained healthcare through relationships with practitioners had settled in Victoria by the burgeoning profession in Europe: Osteopathic healthcare is now provided in 1939,13 and the Australian Osteopathic in August 1936, 37 members of the every continent except Antarctica and is Association was founded there in 1955. In American Osteopathic Association practised in more than 50 countries.* New Zealand, osteopathic practice dates arrived in London at the end of a back to the 1930s when it arrived from European tour that had visited Holland, America. Specific practitioner details are Germany, Austria and France.19 scarce, but US-trained practitioners were recorded at that time in both the north and south islands.
* Based on data collected by the Osteopathic International Alliance and the UK’s General Osteopathic Council. Current models and scope of practice
Osteopathic practitioners currently work By 1924, 38 states had legally recognised within different legal and regulatory the concept of the osteopathic physician Osteopathic Physician structures around the world, resulting in and by the early 1930s the curricula of A person with full, unlimited medical varying permitted scopes of practice. In the osteopathic colleges closely resembled practice rights and who has achieved some countries, such as the USA, they those of regular medical schools. the nationally recognised academic and have full medical licensure that gives professional standards within his or her de facto equality with the mainstream Nevertheless, in 1938, medical doctors country to practise diagnosis and provide medical profession. In others, such were still forbidden to engage in any treatment based upon the principles as Australia and the UK, the title of professional relationship with osteopathic of osteopathic philosophy. Individual 13 ‘osteopath’ is protected so that only physicians.20 During World War II, countries establish the national registered individuals may use it and in osteopathic physicians were not allowed academic and professional standards for these countries osteopaths take full clinical to practise in military service but played Osteopathic Physicians practising within responsibility for the patient rather than a crucial role in meeting the shortage their countries. work under the authority or direction of of community doctors. This laid the a medical practitioner. However, some foundations for the equality in scope of (Source: OIA, derived from the American countries do not regulate who can call practice that subsequently emerged: in Association of Colleges of Osteopathic Medicine, themselves an osteopath and manual 1963, the US Civil Service Commission Educational Council on Osteopathic Principles therapists may be providing treatment announced that osteopathic physicians Glossary of Osteopathic Terminology, April advertised as ‘osteopathic’ without any and medical doctors were of equal status; 2009.) formal training. osteopathic physicians were accepted as military physicians during the Vietnam Globally, two professional streams War; and by 1974, osteopathic physicians have emerged, largely for historical had full practice rights in 50 states.21 reasons – osteopathic physicians (practising osteopathic medicine) and Today in the US, osteopathic physicians osteopaths (practising osteopathy). (also known as DOs, for Doctor of Osteopathic Medicine) are fully licensed to practise the full range of medical Osteopathic physician care, including prescribing medicines Starting with Missouri in 1897, state and performing surgery. They specialise licensing was gradually introduced across in all areas of medicine, ranging from the US, making registration necessary to primary care disciplines such as family practise any kind of medicine. The relative medicine, general internal medicine and standing and relationship of osteopathic paediatrics, to specialised disciplines such practitioners and medical doctors evolved as neurosurgery, radiology, oncology and over several decades. psychiatry. (For details of the educational pathways for osteopathic physicians see Chapter 3). However, while osteopathic physicians Osteopath (DOs) and medical physicians (MDs) Outside the US, the development of Osteopath have many things in common, osteopathic osteopathy has followed a different path A person who has achieved the medicine is a parallel branch of American as, from early on, osteopaths were not nationally recognised academic and medicine and retains a distinct philosophy, licenced to prescribe drugs, perform professional standards within his or training system and approach to patient surgery or assist in childbirth, yet were her country to independently practice care.22 The scope of practice for able to practise manual and manipulative diagnosis and provide treatment based osteopathic physicians extends beyond procedures within the law.24 upon the principles of osteopathic manual therapy, but their healthcare 14 philosophy. Individual countries establish philosophy is rooted in osteopathic Osteopaths in Europe and Australasia thus the national academic and professional principles, and manual diagnosis and developed within a more limited scope of standards for Osteopaths practising treatment techniques still play a strong practice, concentrating on these manual within their countries. role in both training and practice. techniques and the pursuit of a natural based approach to healthcare. In many (Source: OIA, derived from the American There are no osteopathic training countries the osteopath model suited Association of Colleges of Osteopathic Medicine, programmes outside the US that qualify the regulatory framework. This enabled Educational Council on Osteopathic Principles an individual to practise as an osteopathic Glossary of Osteopathic Terminology, April osteopaths to practise recognised, safe 2009.) physician in the US. However, American manual and manipulative therapies so osteopathic physicians have unlimited long as they did not purport to be practice rights as doctors in more than medical doctors, although historically 60 countries. they often faced opposition from the medical profession. Osteopathic physicians trained in Europe are medical doctors (MDs) with Over time, osteopathic teaching postgraduate training and education in programmes have become more osteopathic medicine. Governmental academic and the pursuit of evidence- regulatory systems for osteopathic based medicine and best practice has physicians exist only in the UK and France; been embraced as a basic tenet for the in other countries regulation is by the practice of osteopathy. Today much of general medical councils. In most EU the osteopathic philosophy is exemplified countries medical councils accept that by the current terminology of the MDs with postgraduate qualifications in biopsychosocial approach to healthcare, osteopathy practise osteopathic medicine growing in acceptance worldwide. as a branch of complementary medicine. Osteopathic physicians in five European countries collaborate to promote and maintain standards of osteopathic practice under the umbrella of the European Register for Osteopathic Physicians (EROP)23 (see Chapter 3). Scope of practice varies between ‘Heilpraktiker’, which provides an umbrella The World Health different jurisdictions. In several countries for those professions with primary contact Organization’s 2009 osteopaths operate as autonomous not yet recognised; in Portugal, osteopathy resolution primary contact or ‘first contact’ is a recognised profession, but only The WHO’s 2009 resolution practitioners; while in others ‘diagnosis’ recently has the Portuguese Parliament (WHA62.13) on traditional medicine by anyone other than a medical doctor is agreed to regulation; in Norway anyone urged Member States ‘to consider, where not allowed and osteopaths can only work may call themselves an osteopath and appropriate, including traditional medicine on referral. practise as such, because osteopathy is into their national health systems’.26 How currently not regulated or recognised, this might be done would depend on 15 Legal recognition and regulation of although the profession is applying national capacities, priorities, legislation osteopathy has taken place at different for ‘authorisation’; countries where and circumstances, and evidence of safety, times and reached different stages across osteopathy is practised but does not have efficacy and quality. The resolution also countries. In Australia, New Zealand and formal recognition include Austria, Cyprus, urged Member States ‘to consider, where the UK osteopaths are regulated by law Denmark, Greece and Sweden (see appropriate, establishing systems for the and practice requires registration with the Chapter 3 for more detail on recognition qualification, accreditation or licensing of 25 relevant regulatory authority. In Australia, and regulation). traditional medicine practitioners’. regulation of the osteopathic profession commenced in the 1970s and is now In the US, there is no licensing or Publication by the WHO of a series of organised nationally. In the UK, osteopathy registration of osteopaths who are benchmarks for basic training for selected enjoyed public support and was practised not also qualified doctors. Osteopaths types of healthcare practices is part of under common law and profession- are prohibited from calling themselves the implementation of the resolution. In based regulation before formal statutory osteopaths; in the states where they are the benchmark for osteopathic care, the regulation in 1993 led to compulsory allowed to practise, they are registered WHO states that ‘ideally, countries would registration. In New Zealand, regulation as massage therapists and can only work blend traditional and conventional ways of took effect in 2004. as such. providing care in ways that make the most of the best features of each system and In other European countries and The permitted scope of practice for allow each to compensate for weaknesses elsewhere, regulation has taken on the osteopaths in any country may be defined in the other’.27 nuances of local legislation. For example: by specific osteopathy-related legislation in Italy, osteopathy has recently been and/or by laws governing who is allowed recognised as a profession, but not to provide other medical or healthcare formally part of healthcare, following the services. A more detailed look at the passing of a law in December 2012; in regulation and scope of practice of Belgium a law legalising the practice of osteopaths in different countries is given in osteopathy was passed in 1999, but only Chapter 3. now is the government taking steps to implement this legislation and to introduce regulation; in Germany, osteopaths work under the legal framework for Chapter 2 Practitioners, patients and the scale of osteopathic practice
KEY POINTS l More than half of patients were seeking help for pain. Acute patients most commonly presented with problems due to local pain and restricted Practitioners motion. For chronic patients their pain was more l the OIA 2013 survey of 33 countries identified likely to be over a larger area. at least 87,850 osteopathic physicians worldwide, a 70% increase over the past decade. The vast l the range of presenting symptoms is very diverse, 16 majority (82,500) are in the US, where in 2012 but all surveys indicate that musculoskeletal osteopathic physicians accounted for 7.2% of US back pain is the most common condition among physicians. osteopathic patients.
l the survey identified around 43,000 osteopaths l For both acute and chronic patient groups, the worldwide, nearly triple the number a decade ago. lumbar spine, neck, thoracic spine, thorax, and The countries with the largest number are France, pelvic area were the most frequent areas with Germany, Italy, UK, Australia, Belgium and Canada, problems. which together accounted for almost 38,000 practitioners. l In countries that do not have wide coverage of private health insurance, most osteopathy l the total number of students enrolled at US treatment is self-funded by patients. osteopathic medical schools has risen from 14,409 in 2006-7 to 21,741 in 2012-13. The OIA 2013 Practice characteristics survey identified 25 countries with osteopathy l the most common work environment for both training schools or universities: the countries osteopathic physicians and osteopaths is private where data were available reported 14,750 practice, with or without partners. According to enrolled osteopathy students, of whom 10,000 the OIA 2012 survey, about half of all osteopathic were in France. practitioners work at least seven hours a day. In both professional streams, part-time working is Patients common. l Osteopathic practitioners treat patients of all ages, from birth to very old age. The OIA 2012 survey l the majority of practitioners work as primary found one-third of patients were between 31 and care physicians or generalist osteopaths. In the US, 50 years old. Nearly a quarter (23.4%) were aged around 60% of practising osteopathic physicians 18 and younger, including 8.7% below the age of 2. work in the primary care specialties of family medicine, general internal medicine, paediatrics, l In the OIA 2012 survey, acute, sub-acute and and obstetrics and gynaecology. Most osteopaths, chronic conditions were similarly cited by patients even if they have an area of particular interest, as their reason for seeking osteopathic treatment; treat a wide range of patients and conditions. in addition, around one in five patients attended for a general osteopathic check-up. l Osteopathic manipulative treatment (OMT) is a Relationship with the wider healthcare core activity for both osteopathic physicians and system osteopaths. The OIA 2012 survey found that more l As well as examples of formal integration of than a quarter of US and EU osteopathic physicians osteopathic healthcare within national healthcare spent more than half their work time delivering systems, osteopaths work constructively in parallel OMT, although almost half said it represented less and in communication with physicians and other than 10% of their work. Among osteopaths, more healthcare professionals. than 90% spent more than half their time delivering 17 OMT. l the OIA 2012 survey found that a majority of patients had attended consultations with doctors l several different osteopathic techniques are or other healthcare providers before presenting typically used to treat a single patient. These cover for osteopathic treatment. This was true both rhythmic techniques, short precise impulses, joint for patients of osteopathic physicians and of positioning techniques and very gentle specifically osteopaths. applied pressures. Profession demographics l Osteopathic practitioners commonly integrate osteopathic techniques with other healthcare l the osteopathic profession is relatively ‘youthful’. treatments such as pain medication, standard In the US, 58% of osteopathic physicians are under healthcare and complementary therapies. The OIA the age of 45. The 2012 OIA survey found that 2012 survey found that around 39% of the last 10 around one-third of osteopaths were below the acute patients were taking medication for pain in age of 40, although there is considerable variation addition to osteopathic treatment, while 42% of between individual countries. the last 10 chronic patients were doing so. l the proportion of female practitioners has l physiotherapy, massage and a range of increased. In the US, women now account for complementary medicine techniques are commonly more than a third of all osteopathic physicians provided in addition to osteopathy, both for acute and in the under-35 age group women outnumber and chronic conditions. According to the OIA men. The OIA 2012 survey found that 48.7% of 2012 survey, around 27% of patients had received responding osteopaths were female; men are now at least one additional treatment. the minority among osteopaths below the age of 30, although again there is considerable variation between individual countries. The size and growth of the profession
Number of practitioners Data on osteopathic physicians are more The OIA 2013 survey was not exhaustive Historically, data has not been collected complete than for osteopaths as they are and some countries did not respond. The on the overall number of practitioners registered doctors and a large majority of UK Register of Osteopaths held by the worldwide so the Osteopathic the world’s osteopathic physicians practise General Osteopathic Council includes International Alliance (OIA) wanted to in the US, where licensing was introduced registrants who are resident and practising address this gap in information about the early on. Overall, the OIA 2013 survey outside the UK, including in 20 countries osteopathic profession. The most reliable identified at least 87,850 osteopathic not included in the OIA 2013 survey, data on practitioner numbers comes from physicians worldwide, of whom the vast illustrating minor pockets of practice for majority (82,500) are in the US. instance in the Far East, Middle East and 18 countries with mandatory registration for practitioners. However, these data only Caribbean. Taken together, as mentioned cover a limited number of states. Assessing the total number of osteopaths in Chapter 1, these data demonstrate globally is more difficult as many countries that osteopathic healthcare is practised in In order to obtain a more complete do not regulate and/or register the more than 50 countries overall. picture of the global size of the profession, profession so the aggregated data includes the OIA from January to March 2013 a number of estimates. Overall, the OIA Growth of the profession carried out an informal survey (the 2013 survey identified around 43,000 The OIA 2013 survey also asked for OIA 2013 survey) across more than 30 osteopaths worldwide. In nominal terms, data or estimates of the number of countries where osteopathic healthcare the countries with the largest number practitioners 10 years ago. These data was known to be practised. For are France, Germany, Italy, UK, Australia, were less robust because data collection each country, the survey was sent, as Belgium and Canada, which together was less active a decade ago, but the appropriate, to the regulator, professional account for almost 38,000 practitioners. available figures confirm the significant associations, and principal schools and/or When the number of osteopaths growth in both branches of the profession. individual contacts. is compared as a proportion of the Ten years ago there were around 51,300 population, the countries with the highest osteopathic physicians, compared with Table 2.1 lists the data collected for the proportion of osteopaths are France, the survey’s current figure of 87,850; 33 participating countries and provides Belgium, Switzerland, New Zealand and Italy. this represents a growth of more than a snapshot of the current scale of two-thirds (71.9%) in the number. osteopathic practice around the world. Globally, osteopathic physicians Similarly, the survey responses suggest Where exact information was not outnumber osteopaths overall. However, there were around 14,400 osteopaths available, estimates have been provided. outside the US, the number of osteopaths in the participating countries, compared This is the first time that data on the worldwide is about eight times the with the current figure of around 43,000; profession has been collected on this scale. number of osteopathic physicians. this means the number of osteopaths worldwide has nearly tripled over the past decade. Table 2.1 Number of osteopathic practitioners by country
Country Osteopathic physicians Osteopaths total no. of practitioners, data sources per 100,000 of population* Australia 1,725 7.8 Osteopathy Registrant Data at December 2012; Osteopathy Board of Australia
Austria 30 c. 500-600 6.1-7.3 Estimated Belgium 1,539 14.7 Social Security Instances
Brazil 47 0.02 Registro Brasileiro dos Osteopatas Canada 20 c. 1,500 2.4 COA membership; estimated Croatia c. 16 0.4 Estimated Cyprus c. 11 1.0 Estimated Denmark 15 40 0.7 Estimated; Danish Association of Osteopaths Egypt c. 35 0.04 Estimated Finland c. 300 5.7 National Authority for Medicolegal Affairs France 1,600 17,460 28.9 Directorate for Research, Studies, Assessment, and Statistics (DREES), September 2012 data Germany 2,300 c. 5,000-7,000 9.0-11.5 BDOÄ; DAAO; VOD; BVO estimated Greece 30 0.3 Greek Osteopathic Association
Ireland 120 2.5 OCI
Israel c. 75 1.0 Estimated 19 Italy 50 c. 5,000-6,000 8.1-9.8 Estimated Japan 275 0.2 Japan Osteopathic Federation
Luxembourg Over 40 7.8 ALDO Malta 1 0.2 Personal communication Namibia 1 0.05 Personal communication Netherlands 630 3.7 Dutch Register
New Zealand c. 400 9.2 Registration data Norway 250 5.3 NOF and estimates Poland 30 0.1 Osteon Polish Academy of Osteopathy Portugal c. 400 3.7 Estimated Russia c. 1,300 0.9 Estimated Singapore 26 0.5 Personal communication
Spain c. 600-800 1.3-1.7 Estimated South Africa 49 0.1 Registration data Sweden 1 c. 200 2.2 Swedish Osteopathic Association and estimate Switzerland 38 c. 850 10.6 SAGOM and estimated; FSO-SVO, CDS UK Unknown small 4,211 6.6 GOSC Register number (only those resident in UK) US 82,500 24.6 AOA Osteopathic Medical Profession Report 2012. (31 May 2012). This includes an estimated 4,773 osteopathic medical school graduates in 2012.
* Population data taken from the CIA World Factbook Figure 2.2 Number of osteopaths in France (2000-2012) (Source: Direction de la recherche, des études, de l’évaluation et des statistiques (DREES))
04/03/2002 4,000 25/03/2007 6,000 01/06/2009 10,106 Figure 2.1 Number of 01/12/2009 11,911 20 Osteopathic Physicians in the US 01/08/2010 13,404 (1935-2012) 01/12/2010 14,356 Data at 31 May 2012 (Source: American 01/01/2011 Osteopathic Association)28 14,252 01/03/2011 14,550 1935 8,265 01/07/2011 15,083 1940 9,503 01/01/2012 17,404 1945 10,984 1950 10,877 1955 11,912 1960 13,281 1965 12,047 1970 13,022 1975 14,231 1980 17,788 1985 22,540 1990 29,461 1995 36,999 2000 44,918 2005 58,512 2010 70,480 2012 77,784*
*The number does not include the 2012 osteopathic medical school graduates. Including an estimated 4773 graduates, there are more than 82,500 DOs in the United States Figure 2.3: Number of UK registered osteopaths (2001-2013) Unlike the figure in Table 2.1, this number (Source: General Osteopathic Council, UK) includes General Osteopathic Council (GOsC) registrants who are resident 2001 3,017 outside the UK. These are often (but not exclusively) people who have trained in 2002 3,165 the UK and then gone to practise abroad 2003 3,317 mostly in unregulated countries where they use their UK registration as a ‘quality 2004 3,464 mark’. The GOsC registrant number 21 2005 3,610 compares with over 250,000 doctors registered with the UK’s General Medical 2006 3,739 Council in 2013. 2007 3,852 2008 4,074 In Australia, the osteopathic profession is the fastest growing allied health profession: 2009 4,187 the number of registered osteopaths has 2010 4,352 increased from 25731 in 1996 to 1,72532 at the end of 2012 (excluding those who 2011 4,442 have not renewed their registration). 2012 4,584 2013 4,688
Until robust aggregated global data are In France, the number of osteopaths available, specific national examples more than quadrupled between 2000 and provide the best detailed accurate 2012 (Figure 2.2). Turning points were in evidence of the growing scale of 2002 when the Kouchner law recognised osteopathic medicine and osteopathy. the profession of osteopathy, and in 2007 Figure 2.1 shows how osteopathic when decrees were passed to regulate physicians have been one of the fastest osteopathic practice. growing groups of healthcare professionals in the US since the mid-1970s. In 2012 In the UK, the number of registered osteopathic physicians accounted for 7.2% osteopaths has risen from around 3,000 at of the total actively licensed US physician the beginning of 2001 (when the Register population.29 By 2020, more than 100,000 had completed its start-up phase) to 4,670 osteopathic physicians are expected to be osteopaths in mid-2013 (Figure 2.3).30 in medical practice in the US. 5000
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0 The osteopathic student In the US, there are currently 29 According to the OIA 2013 survey, there population osteopathic medical schools that will be are around 2,500 osteopathic physician Today’s student osteopathic physicians operating at 37 sites across 28 states students in France, attending 51 private 33 and osteopaths are the next generation during the 2013-14 academic year. schools and 14 universities. In Germany, of osteopathic healthcare professionals so Demand for places at US osteopathic there are around 1,500 medical doctors data on the student population provide a medical schools is strong: for 2012 entry, in osteopathic training, most of whom guide to how the size and profile of the applications to osteopathic medical attend the five pure osteopathic physician 34 profession will continue to evolve. schools were 6.3% higher than the schools, while fewer than 200 receive 35 22 previous year, compared with a 3.1% training at osteopathy schools. The OIA 2013 survey asked about increase for MD programme applicants. the number of schools of osteopathic Entry requirements in terms of grades are The different models for osteopathic healthcare in each country and, where the same for both types of programme. physician education and training are applicable, the current number of discussed in detail in Chapter 3. students. The total number of students enrolled (across all student years) at US osteopathic Student osteopaths Student and graduate osteopathic medical schools has risen from 14,409 The OIA 2013 survey counted 25 36, 37 physicians in 2006-7 to 21,741 in 2012-13. countries with osteopathy training schools Countries have their own traditions of As a result, the number of osteopathic or universities. Not all countries provided higher education leading to practise as physicians graduating from university has student numbers but data from those physicians in osteopathic medicine. In US, seen its fastest ever growth in recent years that did showed around 14,750 currently the pathway is a degree in osteopathic (Figure 2.4). Following a steady increase enrolled osteopathy students, of whom medicine; elsewhere a physician with over the past 50 years, women currently around 10,000 were in France. an MD will undertake postgraduate account for 46% of the total number training in osteopathy before qualifying or of students at US osteopathic medical A number of countries, including some working as an osteopathic physician. Some schools, although there has been gradual that recognise osteopathy, do not countries, such as Canada and Switzerland, decline from the peak of just over 50% currently have training courses so students recognise osteopathic physicians but have in 2006/7 (see ‘profession demographics’ have to go abroad to study. In South no schools or universities for this branch page 53). Africa, for instance, where osteopaths of the profession, so individuals seeking to are regulated by the Allied Health enter the profession must train abroad. Professions Council on a model similar to UK/Australia/New Zealand, there are 49 osteopaths; as there is no school, this would imply they trained elsewhere and then returned to South Africa to set up practice. Figure 2.4 Total US osteopathic medical school graduates per Entry level qualifications year (1935-2012) All osteopathic physicians must complete (Source: American Osteopathic Association38) undergraduate and postgraduate medical studies. As mentioned earlier, in the US 1935 459 the pathway is a degree in osteopathic 1940 447 medicine; elsewhere a physician with an MD will undertake postgraduate training 1945 103 in osteopathy before qualifying or working 1950 373 as an osteopathic physician. 23 1955 459 For osteopaths, the required education 1960 427 and training varies between different 1965 394 countries, depending on the regulatory 1970 432 regimes, but some overall trends are clear. 1975 689 l Osteopaths are being educated to a 1980 1,032 higher academic level than in previous 1985 1,474 decades. Data from the OIA 2012 survey (see page 25 for details of 1990 1,527 this survey) reflects how a majority 1995 1,853 of younger respondents are now 2000 2,298 graduates or postgraduates; nearly 90% of those under the age of 30 2005 2,756 fall into this group (Figure 2.5). This is 2010 3,752 less true for older osteopaths; among 2012 4,773 those aged 60 and over, around 55% had a Bachelor or Master’s degree. In some countries, entrants to osteopathy are now required to have a degree qualification (see Chapter 3).
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0 <=29 30-39 40-49 50-59 >=60 Age Figure 2.5 Osteopaths by educational level and age* * When responding to this question, it appears that some osteopaths (particularly older respondents) Without bachelor did not equate a Diploma qualification with the ‘Without bachelor’ category’. As a result, this category With bachelor is increasingly under-represented as the age of respondents increases. (Source: OIA 2012 survey) With masters 60 Prior qualification in physiotherapy
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l Figure 2.5 also demonstratesWithout how bachelor physiotherapy’ route was taken While these trends in osteopathic over the past 20 years or 2000so it by less than 5% of the responding education are clear, the OIA 2012 survey has become far less commonWith bachelor for osteopaths under the age of 30, data as a whole also suggest that an physiotherapy to be a route into a lower proportion than for the osteopath’s approach to practice, the With masters osteopathy. For many years1000 this older generation of osteopaths who patients treated and treatment outcomes was the traditional pathwayPrior qualification into in physiotheraptrainedy in an era when osteopathy do not vary much with educational level. osteopathy in much of Europe, but was less widely recognised as an it began to decline around 1990 0 independent profession. However, The different models for osteopathy when some schools in France, Italy it should be noted that this ‘post- education and training are discussed in and Switzerland began full-time physiotherapy’ route has never been detail in Chapter 3. osteopathy programmes for students a significant contributor in countries with no previous healthcare training. like Australian, New Zealand or the In the OIA 2012 survey, the ‘post- United Kingdom.
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The most extensive data on osteopathic This survey aimed to create a ‘snapshot Age and gender of patients 39 care patients come from the OIA 2012 of the practice of the profession’, Osteopathic practitioners treat patients survey carried out for Stage 2 of the OIA’s with questions that asked practitioners of all ages, from birth to very old age. The Status Report on Osteopathy. The survey about their most recent 10 patients (or OIA 2012 survey illustrates the spread of was drawn up in collaboration with the 20, for some question topics). Overall patients by age (Figure 2.6). In this sample, World Health Organization (WHO) and there were 1,821 responses worldwide nearly a quarter (23.4%) of patients were its results were presented and discussed at from osteopathic physicians (333) and aged 18 and younger, including 8.7% an OIA-WHO Working Meeting in Paris osteopaths (1,488), covering 18,210 below the age of two years (i.e. 0-1 years). in September 2012. patients in detail, making it the largest Around one-third of all patients were 25 survey to date on osteopathic care between 31 and 50 years old. Patients of * patients. This chapter reports osteopathic physicians and osteopaths had the OIA 2012 survey results as well as similar age profiles (Figure 2.6 shows the examples of other available national data. data for the combined population). Figure 2.6 Age of osteopathic care patients (10 most recent patients)† †The 31-50 year old age range could not be split due to categories used in the original data collection. (Source: OIA 2012 survey)
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* Survey respondents were in North America, South America, Europe (including Russia), Australasia, and Japan.
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0 A number of national surveys of cent were female and 43% male, with l A survey of 1,556 French patients osteopathy patients have found similar age the majority between 30 and 59 years found almost two-thirds (61.5%) and gender profiles (Figures 2.7a-c). Overall, of age. Almost two-thirds of the child were female and that 12% of women the data show there are more female patients aged 0-9 years were babies of patients of childbearing age were than male patients and, while working age 0-12 months (Figure 2.7a).41 pregnant; overall the age profile of adults account for the majority of patients, the French sample was very similar a significant patient group is infants under l A 2004 Australian survey of 2,238 to other studies, but with a more the age of one year. patients (published in 2009) similarly pronounced peak for young babies 43 26 found 63% of patients were female, (Figure 2.7c). l In the UK, around 30,000 people and 46% were aged 30-49, with an currently consult osteopaths every overall age range from birth to over l A survey of 241 osteopathic working day.40 A UK survey in 2009 of 80 years old (Figure 2.7b).42 practitioners in Quebec, Canada 1,630 patients reported 56% per looked at all patients over a two-week period: 62.4% were women, 27.3% men, and 10.3% children (no further Figure 2.7a UK osteopathy patients breakdown was given).44 (Source: Fawkes C, Leach J, Mathias S, Moore A (2010) The Standardised Data Collection Project – Standardised data collection within osteopathic practice in the UK: development and first use of a tool to profile osteopathic care in 2009. London: National Council for Osteopathic Research.)
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Age distribution – all patients Percentage of patients 0-9 3.60 10-19 4.70 20-29 12.10 27 30-39 23.20 40-49 23.50 50-59 18.50 60-69 8.10 70-79 4.70 80+ 1.80
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While not inconsistent with the OIA results, two national surveys from Europe covering osteopathy patients both found a higher proportion (around half) of patients seeking treatment had acute conditions. In the UK, acute onset conditions accounted for 37% of patients, with a further 14% of patients suffering an acute traumatic onset.45 In France, acute onset accounted for 26% of patients and acute post-traumatic for 20%; sub-acute conditions (24%), chronic (20%) and general check-ups (9%) accounted for the remainder of the French patients.46
35 30 25 20 15 10 5 0 Patient pathways to Referral source osteopathic care 22.3% The various routes that lead patients to Friend of patient osteopathic healthcare demonstrate its 29.7% place within the network of healthcare 19.7% disciplines. The OIA’s 2012 survey of Medical Doctor (M.D.) osteopathic practitioners recorded who 23.6% had referred or recommended patients 19.2% for osteopathic treatment. Doctor of Osteopathic 30 Medicine (D.O.) 3.9% For patients of US and European 4.5% osteopathic physicians, referrals were Chiropractor mainly through friends or other physicians 1.8% (in the US a relatively large number of 2.7% referrals came from other osteopathic Chinese medicine physicians (DOs)). A wide range of non- 2.3% physician healthcare and health-related 7.6% practitioners accounted for other channels Physiotherapist 15.0% of access (Figure 2.9). Counselor/ 4.5% psychologist 3.5%
1% Podiatrist 4.1%
1.1% Dietician 1.0%
3.2% Personal trainer 3.5%
8.9% Figure 2.9 Recommendations Massage therapist 6.6% and referrals to osteopathic 5.3% physicians in the US and Europe Other (10 most recent patients) 4.9% US EU (Source: OIA 2012 survey) A similar pattern was found for patients Figure 2.10 Recommendations and referrals to osteopaths visiting osteopaths, except for a lower (10 most recent patients) overall level of referrals from osteopathic (Source: OIA 2012 survey) physicians (DO), largely due to their smaller number outside the US (Figure 2.10). Again the OIA 2012 survey data Referral source appear to confirm that osteopaths are well embedded in the broader Friend of patient 29.1% community of healthcare and health- 31 related professionals across a wide range Medical Doctor (M.D.) 18.5% Doctor of Osteopathic of countries. 6.4% Medicine (D.O.) A separate national survey of patients Chiropractor 1.3% in the UK found that almost 80% had Chinese medicine 4.1% self-referred themselves to the osteopath, but a significant minority overall had been Physiotherapist 10.6% referred by other health professionals Counselor/psychologist 3.4% including general practitioners (6.3%), NHS consultants (0.2%) and other Podiatrist 4.4% 47 healthcare practitioners (5.5%). In Dietician 1.1% this study, referral by family and friends accounted for just 2.4%, suggesting Personal trainer 5.5% that the interpretation of what was Massage therapist 9.1% meant by ‘referral source’ may have been different to the OIA 2012 survey. Other 6.5% Australian Osteopathic Association membership survey data from 2009 and 2012 consistently showed around 90% of patients had self-referred themselves to an osteopath.48
30 25 20 15 10 5 0 Patients’ general health Figure 2.11 General health complaints of most recent 10 acute complaints when seeking and 10 sub-acute/chronic patients osteopathic treatment (Source: OIA 2012 survey) Responses to the OIA 2012 survey’s query about the general type of complaint presented by patients were similar across Complaint osteopathic physicians and osteopaths and are illustrated for all respondents in Figure Local pain 20.4% 32 2.11, covering patients with both acute Large area pain 18.0% and sub-acute/chronic conditions. More than half of patients were seeking help Pain radiating to extremity 15.7% for pain. Acute patients most commonly Restricted motion 18.9% presented with problems due to local pain and restricted motion. The pattern Impaired ADL 16.5% differed slightly for chronic patients in that Psychological change 7.9% their pain was more likely to be over a larger area. Other 2.7%
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0 Physical location of Figure 2.12 Anatomical area of complaints of most recent 10 acute presenting health complaints and 10 sub-acute/chronic patients There have been a number of studies into (Source: OIA 2012 survey) the specific anatomical location of the health condition that leads patients to seek Area of complaint osteopathic care. The range of presenting Head symptoms is very diverse, but all surveys 8.3% indicate that musculoskeletal back pain Neck 14.8% is the most common condition among 33 osteopathic patients. Shoulder 9.6% Elbow 2.7% The OIA 2012 survey found a similar profile of complaints across osteopathic Hand/finger 2.3% physicians and osteopaths, and for acute Thoracic spine 10.2% and chronic condition patients (Figure 2.12). For both acute and chronic patient Lumbar spine 18.3% groups, the lumbar spine, neck, thoracic Pelvic area 9.2% spine, thorax, and pelvic area were the most frequent areas with problems. Abdomen 4.6%
Thorax 5.0% Data from national osteopathy patient surveys in the UK, France, Australia and Hip 6.0% Canada show similar overall results to Knee each other. Patients present with a wide 5.6% range of symptom areas but practitioners Ankle 3.3% predominantly treat musculoskeletal conditions, with the lumbar spine and neck (cervical spine) the most common area of symptoms.
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0 l In the UK, the lumbar spine Osteopathic care of children A total of 407 patients and 1,500 clinic accounted for 36% of presenting Children, particularly young babies, make visits were included and the age profile symptoms, with the neck, sacroiliac/ up a distinct proportion of osteopathic showed that almost half (46%) of the pelvis/groin, shoulder and thoracic patients, as detailed in the section on children were under five years. Diagnoses spine comprising a further 36% of the ‘Age and gender’ page 25. One study has covered a wide range of common 49 conditions treated by osteopaths. looked in detail at the characteristics of paediatric conditions; overall, 43.5% patients under 18 years and their use of of visits covered non-musculoskeletal l In France, musculoskeletal pain osteopathic manipulative treatment in diagnoses (Table 2.2). 34 accounted for 62% of consultations, the US.53 with 43% of patients suffering from lumbar, cervical, dorsal spine/thorax, sacroiliac/gluteal or general spinal Table 2.2 Age at first visit of children seen in US osteopathic pain.50 manipulative medicine clinics
l In the 2004 patient survey in Patient Age Group % of child patients Percentage of all clinic visits for Australia, the most common first each age group with non- presenting symptoms (patients could musculoskeletal diagnoses (%)* list up to three symptoms) were Infant, 0-11 months 15.2% 33.7% lumbar spine pain (27%); neck pain (25%); and headaches (10%). Preschool, 1-4 years 30.7% 64.0% The majority of patients had two School, 5-12 years 31.2% 48.8% presenting symptoms, usually a mixture of pain in the low back and Adolescent, >12 years 22.9% 17.9%
neck, with a smaller presence of * Data include only clinic visits with diagnoses other than somatic dysfunction (Source: Lund G, Carreiro thoracic spine pain and immobility as J (2010) Characteristics of Pediatric Patients Seen in Medical School-Based Osteopathic Manipulative well as headaches.51 Medicine Clinics. Journal of the American Osteopathic Association. 110(7):376-380.)
l A patient survey in Quebec, Canada, also found 70% of patients consulted an osteopath because of musculoskeletal pain, in particular lumbar and cervical. In addition, functional problems (digestive in adults and children, headaches and migraines, fatigue, chronic pain) were also represented.52 The profile of paediatric conditions varied Diagnoses for patients aged 0 to 11 months (n=196)* for each age group. For instance, for Diagnosis Visit count, no. (%) babies under the age of one, more than Most frequent non-musculoskeletal diagnoses two-thirds of clinic visits were for the musculoskeletal diagnoses of torticollis Otitis media 24 (12.2) or skull/face deformity, whereas for Feeding problem 11 (5.6) children aged 1-4 years the most common condition was otitis media, and for older Gastroesophageal reflux disease 9 (4.6) children headache, scoliosis and lumbar Fussy infant/baby 7 (3.6) 35 back pain were the most prominent Abdominal pain 5 (2.6) (Table 2.3). Overall, the profile of diagnosed conditions, particularly for Most frequent musculoskeletal diagnoses children up to the age of 12, was distinct Torticollis 74 (37.8) from that for adults. Skull or face deformity 61 (31.1) Muscle spasm 9 (4.6) Abnormality of gait 2 (1.0) Cervicalgia, dislocated elbow or myalgia 1 (0.5) each
Diagnoses for patients aged 1 to 4 years (n=433)*
Diagnosis Visit count, no. (%) Most frequent non-musculoskeletal diagnoses Otitis media 149 (34.4) Upper respiratory infection 24 (5.5) Behavioural problems 15 (3.5) Sleep disturbance 14 (3.2)
Asthma 9 (2.1) Most frequent musculoskeletal diagnoses Skull or face deformity 68 (15.7) Torticollis 33 (7.6) Table 2.3 Diagnoses for Head injury 11 (2.5) children seen in US osteopathic Muscle spasm 11 (2.5) manipulative medicine clinics, by Abnormality of gait 7 (1.6) age group * Data include only clinic visits with diagnoses other than somatic dysfunction Table 2.3 Diagnoses for children seen in US osteopathic manipulative In the UK, the NCOR survey similarly medicine clinics, by age group (continued) looked at symptoms and treatment for babies and children up to the age of Diagnosis For Patients Aged 5-18 (n=742)* 14 years, although the numbers were Diagnosis Visit count, no. (%) relatively small.54 The older teenagers Most Frequent Non-musculoskeletal Diagnosis 15-19 had a more ‘adult profile’ of symptoms so were not included. Again, Headache 106 (14%) the head/facial area was the most 36 Otitis Media 66 (8%) common symptom area, although abdomen was also prominent for young Behavioral issues 58 (7.8%) babies (Figure 2.13). Symptoms under Asthma 18 (2.4%) ‘other’ included feeding disorders, Celiac disease 12 (1.6%) sleep disturbance, colic symptoms, and continuous crying. Most Frequent Musculoskeletal Diagnosis Scoliosis 108 (14.5%) Lumbar Back Pain 91 (12%) Neck Pain 85 (11.4%) Thoracic Back Pain 68 (9.2%) Unequal leg Length 42 (5.7%)
* Data include only clinic visits with diagnoses other than somatic dysfunction (Source: Lund G, Carreiro J (2010) Characteristics of Pediatric Patients Seen in Medical School-Based Osteopathic Manipulative Medicine Clinics. Journal of the American Osteopathic Association. 110(7):376-380.) Figure 2.13 Symptom areas of UK osteopathy patients under the age of 15 (Source: Fawkes C, Leach J, Mathias S, Moore A (2010) The Standardised Data Collection Project – Standardised data collection within osteopathic practice in the UK: development and first use of a tool to profile osteopathic care in 2009. London: National Council for Osteopathic Research.)
Symptom areas Symptom areas Number of patients (baby 0-12 months) Number of patients in study (age range 1-14 years) in study 37 Other Other 16 10
Abdomen 14 Abdomen 2
Foot 1 Foot 3
Sacroiliac/pelvis/groin 2 Ankle 1
Neck 4 Knee 2
Head/facial area 22 Hip 1
Sacroiliac/pelvis/groin 1
Lumbar 3
Rib cage 3
Thoracic spine 3
Shoulder 1
Neck 3
Head/facial area 11
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0 How much is spent? Who pays, and does health Australia There is only very limited national data insurance cover osteopathic In Australia, individual patients may be on actual total annual expenditure on healthcare? able to reclaim the cost of osteopathy osteopathic healthcare. Healthcare funding regimes vary through the Chronic Disease Management significantly between countries, as does (CDM) programme introduced in 2004 A detailed recent analysis in Australia the extent to which private health by Medicare (the country’s government of the economic importance of the insurance plays a role in the healthcare funded public health scheme); or through osteopathy profession estimated market. These differences feed through private medical or other insurance; or 38 that Australian patients in 2011-12 to the way osteopathic care is funded. In have their fees paid under government spent around A$210m (US$216m)* countries that do not have a tradition of programmes such as that for retired on osteopathic services, based on an private health insurance, most osteopathy military personnel. The principal sources estimated 2.34 million patient visits over is self-funded by patients. of funding are: private health insurance the year. Given the variations, for instance Medicare rebates; claims under workers’ in fees charged, the total actual amount United States compensation programmes; compulsory is likely to be in the range of A$180m Treatment by osteopathic physicians in the third party (motor vehicle) insurance (US$185m) to A$247m (US$254m).55 US is covered by private health insurance claims and; payments by the Department 60 schemes and government health schemes, of Veterans Affairs. This gross figure is unadjusted for any with parity with other doctors. Thus, in amounts subsequently refunded by addition to private insurance companies, A Medicare claim requires a referral government and insurance schemes (see osteopathic physicians are eligible for from a general practitioner prior to the next section) and compares with more participation and reimbursement from initial consultation and covers up to five than A$124bn for total (government managed care companies and all state individual osteopathic services per year. and non-government, not including and federal government agencies, such as Once referred the osteopath manages capital expenditure) recurrent health Medicare and Medicaid. In 2011, Medicare the osteopathic care plan. The value of expenditure in 2010-11. In terms of payments for all physician services totalled osteopathy claims has risen sharply since privately funded health services in $97.9 billion.58 The proportion relating the CDM programme was introduced. Australia, osteopathic services, on the to services provided by osteopathic In recent years, claims/benefits paid have basis of net expenditure by individuals physicians was not itemised, but risen by around 20% a year. In 2011-12 treated, are estimated in 2011-12 to have osteopathic physicians made up 7.2%59 of there were 86,359 claims for osteopathy 61 made up about 1% of total recurrent the physician population in the US in 2012. and benefits paid out totalled A$4.5m. health expenditure by individuals.56
In the UK, KPMG in 2013 estimated the size of the UK osteopathy market at £288m to £487m, depending on assumptions about the average number of hours worked per week.57
* Using April 2013 exchange rates. All major private health insurers in New Zealand France Australia will cover part of the cost of In New Zealand some private insurance In France, in contrast, where more than osteopathic treatment, although the level companies do reimburse policyholders for 90% of patients have private health of coverage varies between companies. the cost of osteopathic treatment, but this insurance to supplement the national The value of claims has increased since is not universal and is often cash-limited health system, the situation is very the mid-1990s, with a big jump since on an annual basis. In addition, the state different. A non-representative survey mid-2007 as a result of a policy change by run Accident Compensation Corporation of more than 1,550 osteopathy patients a major private insurer. In 2011-12, claims (ACC) subsidises the cost of treatment found that 61% were reimbursed by for osteopathic services to private health for all injuries suffered as the result of private insurance for their osteopathic 39 insurers totalled nearly 750,000, with accidents, wherever suffered. Osteopathic care.67 associated benefits of A$24m paid out treatment is dealt with on the same for claims.62 Around 43% of the fees paid basis as similar professions and is subject by patients with private health insurance to the same outcome measures and Other European countries were recovered as insurance benefits. financial metrics. An analysis showed that Coverage by state and private health for the years 2003-4 to 2007-8, charges insurance schemes varies across other Overall, however, despite Medicare and by osteopaths accounted for 8% of the European countries. For example, national private health insurance payments, it is gross amount paid under all claims by the health insurance cover is also available estimated that Australian patients privately ACC.64 in Austria, Finland and Germany. Private funded around 85% of total expenditure health insurance cover is also available on osteopathy in 2011-12.63 UK in Austria, Belgium, Finland, Germany, In the UK, some private health insurance Ireland, Italy, Malta, Norway, Portugal policies will cover osteopathy but less than and Sweden. In both instances the level 11% of the population has private health of cover varies in terms of the cost of insurance.65 As a result, the majority of each treatment and the total number of osteopathic treatment is paid for directly treatment sessions. by patients. A non-representative survey in 2009 covering 1,630 patients found that 89% of patients self-funded the cost of initial appointments.66 Private health insurance covered the cost of osteopathy for less than 7% of the surveyed patients. Less than 1% of patients in the survey had been referred to osteopaths by their National Health Service doctors. A profile of osteopathic practice
Practice setting and time However, US osteopathic physicians are In both professional streams, part- worked more likely than other groups to work in time working is common, with a larger Overall, according to the OIA 2012 hospitals, outpatient clinics, universities proportion of osteopathic physicians than survey data, the most common work and medical institutions (Figure 2.14). osteopaths working less than three hours environment for both osteopathic a day. physicians and osteopaths is private The OIA 2012 survey data suggests that practice, with or without partners. about half of all osteopathic practitioners work at least seven hours a day. 40 Figure 2.14 Work environments for US/EU osteopathic physicians and worldwide osteopaths (Source: OIA 2012 survey)
Osteopathic physicians Osteopaths work work environment environment 25.4% Private oce 43.0% Private oce 39.4% With 1 partner 14.1%
7.9% More than 2 partners 18.2% With 1 partner 16.2% Hospital 3.0% 7.9% Outpatient clinic 2.9% More than 2 partners 13.9% Medical institution 3.9%
10.8% University 6.5% Hospital 5.6% Other 8.5% 10.0% Outpatient clinic 6.0%
7.9% Medical institution 6.0%
20.4% University 6.5%
9.6% Other 6.5% US EU
40 35 30 25 20 15 10 5 0 Length of patient Figure 2.15 Length of average consultation consultations (Source: OIA 2012 survey) Data from the OIA 2012 survey indicate that osteopaths on average spend longer OSTEOPATHIC PHYSICIANS with patients than osteopathic physicians, Intial consultation Follow-up consultation both for initial and follow-ups (Figure Length of consultation % of consultations 2.15). Specifically, osteopaths are more in minutes 0.9% likely to spend longer than 30 minutes on <15 mins average with a patient. This is particularly 8.9% 41 true with respect to initial consultations, 21.8% during which osteopaths spend additional 15-30 mins 46.6% time conducting diagnostic procedures 27.1% – some of which would be categorised 30-45 mins as standard healthcare. This is also borne 31.2% out by data from individual countries: the 34.8% survey of osteopaths in Quebec, Canada 45-60 mins 10.7% found an average consultation time of 55 68 minutes, while for France the available > 60 mins 15.3% 69 data found it was 45 minutes. 2.5%
OSTEOPATHS Length of consultation % of consultations in minutes 0.6% <15 mins 3.5%
15-30 mins 9.2% 21.4%
30-45 mins 25.3% 40.5%
45-60 mins 50.4% 31.8%
> 60 mins 14.6% 2.7%
60 50 40 30 20 10 0 Areas of specialty practice Table 2.4 US osteopathic physicians: self-identified practice specialties* The majority of practitioners work as (1984-2012) primary care physicians or generalist Year family general Paediatric Obstetrics Osteopathic Other osteopaths. and internal and (%) manipulative specialty general medicine adolescent medicine or practice In the US, around 60% of practising (%) (%) medicine osteopathic (%) osteopathic physicians work in the (%) manipulative treatment primary care specialties of family medicine, specialties (%) 42 general internal medicine, paediatrics, and obstetrics and gynaecology.70 Many fill a 2012 37.9% 12.9% 5.7% 4.6% 1.6% 37.3% critical need for physicians by practising 2004 45.5% 8.1% 3.1% 3.8% 1.2% 35.5% in rural and other medically underserved 1994 44.8% 6.6% 2.5% 3.3% 3.3% 35.5% communities. However, Table 2.4 illustrates a shift in recent years away from 1984 56.4% 4.7% 1.8% 2.8% 0.5% 23.7%
family practice and towards the other * The table includes only osteopathic physicians in active practice and out of postdoctoral training. primary care specialties. At the same (Source: AOA Osteopathic Medical Profession Report 2012.) time, more than one-third of osteopathic physicians now work in specialties outside primary care, compared with less than a Figure 2.16 Osteopaths in Quebec, Canada: areas of practice* quarter 30 years ago. * The same osteopath can have more than one type of practice Source: Morin C and Aubin A (2012) Survey on osteopathic practices in Quebec: most common reasons for consultation (Powerpoint presentation.) Quebec: Centre Ostéopathique du Québec and the Registre des Ostéopathes du Québec.
Area of practice % of osteopaths responding
General 98.3%
Perinatal 44.0%
Sports 28.2%
Gynecology 20.0%
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0 There is less data regarding the extent A KPMG survey of UK osteopaths looked Osteopathic treatment is also used for to which osteopaths specialise, and the at the amount of time spent focussing some very specific groups of patients. information that is available suggests that on particular patient groups (Figure These areas of practice include pre- most osteopaths, even if they have an area 2.17). It identified a very small number operative patients before surgery.71 of particular interest, treat a wide range of of osteopaths who practised almost Osteopathic treatments can also be used patients and conditions. For example, the exclusively on older people or infants, and as part of end-of-life care, for instance for survey in Quebec, Canada illustrates how a minority who focused primarily on a the management of pain and to improve almost all osteopaths with a particular specialist group but also saw other types respiratory function in patients receiving 72 area of practice also offer general practice of patients as well. palliative care. 43 (Figure 2.16).
Figure 2.17 UK osteopaths: percentage of osteopathic practice time spent on particular groups in a normal week (Source: KMPG ‘Report A – How do osteopaths practice?’, survey commissioned by the General Osteopathic Council)
Patient group Number of respondents (n=208) 0 50 100 150 200 250
98.3% Older people Other adults Children Infants Pregnant women Sportsmen/women Animals
No response None 0-10% 10-50% 50-90% >90%
Percentage of time spent with patient group
100 100 150 200 250 50
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0 Time spent on osteopathic Figure 2.18 Time spent delivering osteopathic manipulative treatment manipulative treatment (OMT) (OMT) (Source: OIA 2012 survey) Osteopathic manipulative treatment Osteopathic physicians practising OMT (OMT) is a core activity for both osteopathic physicians and osteopaths. % of time % of osteopathic providing OMT physicians Not surprisingly, given their broader scope 44 of practice, osteopathic physicians spend <10% 48.2% less of their time providing osteopathic manipulative treatment (OMT) than 10<30% osteopaths, and more time delivering 14.8% other aspects of healthcare. Yet OMT still takes a central role in many osteopathic 30<50% 8.9% physicians’ practice.
According to the OIA 2012 survey, more >=50% 28.2% than a quarter of US and EU osteopathic physicians said they spent more than half their work time delivering OMT Osteopaths practising OMT (Figure 2.18), although almost half said it represented less than 10% of their work. % of time providing OMT % of osteopaths In the US, almost half of osteopathic physicians in the OIA 2012 survey said <10% 1.8% they had delivered OMT to all their patients over the previous three days; among European osteopathic physicians, 10<30% 1.0% this proportion was lower at just under 25%, but nearly 60% said they delivered 30<50% 5.3% OMT to more than half their patients. An academic study into the use of osteopathic manipulative treatment by US osteopathic >=50% 91.9% physicians in family practice found it was commonly used in one quarter of patient consultations; this was consistent with the 31% of patients in the study who were diagnosed with a (somatic) dysfunction of the body framework.73
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0 Among osteopaths, the OIA 2012 survey Osteopathic technique Average number of patients on whom technique was used found that more than 90% spent more 6.0 than half their time delivering OMT Soft tissue (a) (Figure 2.18). Standard healthcare also 5.3 featured in the practitioner-reported Articulation (a) 4.4 distribution of work time, and this is likely 4.3 to include broader health activities, such HVLA (b) 4.4 as checking or monitoring blood pressure, 3.5 discussing how to manage conditions 4.9 Body adjustment (b) 45 (e.g. diabetes) and providing advice on 3.2 preventative health measures. Myofacial (c) 6.1 4.7 5.2 Muscle energy (c) Osteopathic techniques used 3.8 in treatment 4.4 Counterstrain (c) The OIA 2012 survey data showed that 2.9 several different osteopathic techniques 4.6 were commonly used on a single patient. Functional (c) 4.2 As mentioned above, osteopathic 4.1 manipulative treatment (OMT) is a core Positional release (c) 4.2 activity for both osteopathic physicians 6.2 Cranio-sacral (d) and osteopaths. OMT employs an array 5.0 of approaches that can be broadly 5.5 categorised as: Biodynamics (d) 3.9 6.0 l rhythmic techniques (a) Balanced ligamentous (d) 4.1 l short precise impulses (b) 3.1 l joint positioning techniques (c) Visceral (d) 4.1 l very gentle specifically applied pressures (d). 3.6 Lymphatic (d) 3.0
Chapman reflexes (d) 3.0 Figure 2.19 Osteopathic 2.3 manipulative treatment (OMT) Triggerpoint (d) 3.0 methods used by osteopathic 3.4 5.0 physicians and osteopaths on Other 4.1 their most recent 10 patients (Source: OIA 2012 survey) Osteopath Osteopathic physician
8 7 6 5 4 3 2 1 0 The OIA 2012 survey illustrated how both Figure 2.20 UK osteopathy patients under the age of 15 – treatments osteopathic physicians and osteopaths given at first appointment utilise a wide range of these techniques in (Source: Fawkes C, Leach J, Mathias S, Moore A (2010) The Standardised Data their practice (Figure 2.19). In the graphic, Collection Project – Standardised data collection within osteopathic practice in the UK: the techniques are arranged according to development and first use of a tool to profile osteopathic care in 2009. London: National this broad classification. The data confirms Council for Osteopathic Research.) that each patient receives a number of different types of OMT. Treatments given at first appointment (Baby 0-12 months) 46 The OIA 2012 survey illustrated Types of treatment % of patients some differences in the detail of what techniques are used: data on the most Soft tissue 6.1% recent 10 patients showed that osteopaths made greater use than osteopathic Articulation 2.0% physicians of soft tissue techniques and articulation, while osteopathic physicians Cranial technique 58.6% put more emphasis than osteopaths on cranio-sacral, myofacial and balanced Functional technique 6.1% ligamentous tension. Visceral 7.1% Another study in the UK looked specifically at the types of osteopathic Education 8.1% treatment provided to babies and children (Figure 2.20). This demonstrated Relaxation advice 1.0% that cranial techniques were dominant for children below the age of 10, and Dietary advice 2.0% particular for young babies. Exercise 4.0%
Other 5.1%
Treatment for children at first appointment
Types of treatment % of patients 100 Other ICE Electrotherapy 80 Exercise Teen (10-14 yrs) Dietary advice Child (5-9 yrs) Relaxation advice Toddler (1-4yrs) 60 Education Myofascial release Visceral Functional technique 40 Strain/counterstrain Muscle energy Cranial techniques 20 HVLA thrust Articulation Soft tissue 0 No treatment
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
60 50 40 30 20 10 0 Treatments given at first appointment (Baby 0-12 months)
Types of treatment % of patients
Soft tissue 6.1%
Articulation 2.0%
Cranial technique 58.6%
Functional technique 6.1%
Visceral 7.1%
Education 8.1%
Relaxation advice 1.0%
Dietary advice 2.0%
Exercise 4.0%
Other 5.1%
Treatment for children at first appointment
Types of treatment % of patients 100 Other
ICE 47 Electrotherapy 80 Exercise Teen (10-14 yrs) Dietary advice Child (5-9 yrs) Relaxation advice Toddler (1-4yrs) 60 Education Myofascial release Visceral Functional technique 40 Strain/counterstrain Muscle energy Cranial techniques 20 HVLA thrust Articulation Soft tissue 0 No treatment
0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
60 50 40 30 20 10 0 Integrating manipulative Figure 2.21 Number of patients (acute and sub-acute/chronic therapy with other conditions) taking drugs for pain management in addition to treatments osteopathic treatment (most recent 10 patients) Osteopathic practitioners commonly (Source: OIA 2012 survey) integrate osteopathic techniques with other healthcare treatments such as pain Number of % of practitioners responding medication, standard healthcare and patients taking drugs complementary therapies. 1 9.2% 48 2 17.1% The OIA 2012 survey found that around 3 16.7% 39% of the most recent 10 acute patients 4 13.2% were taking medication for pain in addition to osteopathic treatment, while 42% of 5 14.0% the last 10 chronic patients were doing so 6 8.5% (Figure 2.21). 7 6.9% 8 7.6% A study into osteopathic manipulative treatment (OMT) in US family practice 9 3.1% found that patients were more likely to 10 3.8% receive manipulative therapy if they were taking painkillers, non-steroidal anti- inflammatory agents, or muscle relaxants. The authors suggested this could indicate osteopathic physicians in US family practice may be more likely to use OMT to complement medication rather than as an alternative to it. However, the study cautioned that the comparison group may not have been appropriate and pointed to a clinical trial of OMT in patients with sub- acute low back pain that had concluded the osteopathic treatment group used less medication than the standard care group (see Chapter 4 for a review of the evidence on osteopathic treatment of pain).74
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0 In the OIA 2012 survey, for US/EU Figure 2.22 Number of patients receiving additional treatments in osteopathic physicians, 48% of acute addition to osteopathic care (most recent 10 patients) and 53% of chronic patients received (Source: OIA 2012 survey) standard healthcare in addition to osteopathic treatment; for osteopaths, 33% of acute and 39% of chronic patients received standard healthcare in Average number of patients receiving treatment (out of most recent 10 patients) addition to osteopathic treatment. As Type of treatments mentioned in Chapter 1, a core aspect Acupuncture 2.6 49 of the osteopathic philosophy includes the elements of standard healthcare that Homeopathy 2.0 encourage patients to develop attitudes Naturopathy 1.4 and lifestyles that are not only curative but Phsyiotherapy 4.3 also help to prevent disease. Massage therapy 2.9 Training therapy 1.7 In the UK NCOR survey, the majority of osteopath consultations included Other CAM 1.4 education (73%) and information-giving (84%), such as advice on self-management strategies (88%), with many patients being given more than one strategy to try.75
The OIA 2012 survey also illustrated the types of non-osteopathic additional treatments delivered by osteopathic physicians and osteopaths to their most recent 10 patients. Physiotherapy, massage and a range of complementary medicine techniques were commonly provided in addition to osteopathic manipulation, both for acute and chronic conditions (Figure 2.22). Around 27% of patients had received at least one additional treatment.
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Traditional, complementary and alternative In contrast, the degree of osteopathy’s l In Australia, formal referral therapies are increasingly formally used integration (or non-integration) with arrangements exist for osteopathic within existing healthcare systems around the national healthcare system varies services within the public healthcare the world.76 As well as examples of formal considerably between different countries. system and patients are eligible for integration of osteopathic healthcare a government subsidy under the within national healthcare systems, l The UK illustrates one model of Chronic Disease Management Plan there is also evidence of osteopaths integration whereby the state-funded when referred to an osteopath by a working constructively in parallel and in National Health Service is allowed medical practitioner (see insurance 50 communication with physicians and other to offer and pay for osteopathy, but section page 38). A national survey healthcare professionals. However, in any the decision whether to do so is in 2005 found that around 16% of country, the relationship of osteopathic made locally. As a result, osteopathy osteopathic patients presented via healthcare with the national health is only available on the NHS in some referral from a conventional medical system is usually influenced – and often areas of the UK. Where osteopathy practitioner.78 A recent study into constrained – by its level of recognition is available within the NHS, a referrals by 585 rural and regional and regulation (see Chapter 3). referral by a primary care general Australian general practitioners in practitioner doctor is necessary New South Wales found the majority unless it is integrated into a primary (64.1%) referred to a chiropractor Formal integration or secondary care service. In England, or osteopath at least a few times per Osteopathic physicians are fully licensed Department of Health guidance to year, while 21.7% said they would not to practise the full range of medical the NHS on musculoskeletal services refer to a chiropractor or osteopath care and, in the countries where includes developing capacity in under any circumstances (no separate osteopathic medicine is prevalent they primary care by offering a wider range data were published specifically for are fully integrated into the national of non-surgical alternatives (including osteopathic referrals).79 Most GPs medical system. In the US, for instance, osteopathy), and a role for osteopaths were aware of local chiropractors osteopathic physicians specialise in all in multidisciplinary Clinical Assessment and osteopaths in their area, but areas of medicine and their status has and Treatment Services.77 However, only 6% had a personal professional parity with medical physicians. US-trained most osteopathic healthcare in the UK relationship with a specific individual osteopathic physicians are accorded is still accessed privately and operates osteopath. The overall results were the same unlimited scope of practice as outside the NHS. in line with an earlier national survey their MD counterparts, which includes that had found 44% of Australian prescribing rights, managed care contracts, general practitioners rated osteopathy surgery, and the ability to employ the as moderately or highly effective, 23% latest medical technologies and to obtain regularly referred to osteopaths, but staff privileges at hospitals. 21% would actively discourage patient use of osteopathy.80 l In New Zealand, osteopaths are a Figure 2.23 Average number of doctors or other healthcare providers part of the formal referral system, that patients consulted before seeking osteopathic treatment (most and have their treatments subsidised recent 10 patients) under the state-funded Accident (Source: OIA 2012 survey) Compensation Corporation scheme for patients whose conditions arise from an event or accident, whether Average number of at home or at work. A number of providers consulted % of practitioners responding osteopaths also hold state-funded 51 contracts for various specialist 0 10.1% provision schemes within which 1-2 63.3% they manage rehabilitation pain management and return to work 3-5 23.3% schemes. 5-7 2.6% >7 0.7% Prior consultations with other healthcare professions One question is the extent to which patients seek out osteopathic practitioners because other types of healthcare providers have not fully addressed their health conditions and/or concerns. This is a separate issue to that of how patients accessed, or were referred for, osteopathic treatment which is considered in the section on patient pathways above.
The OIA’s 2012 survey found that a majority of patients had attended consultations with medical doctors or other healthcare providers before presenting for osteopathic treatment. This was true both for patients of osteopathic physicians and of osteopaths (Figure 2.23).
80 70 60 50 40 30 20 10 0 Referrals by osteopaths to A total of 13% of UK patients overall were The majority of onward referrals were to other health services referred on by their osteopath to other a patient’s general practitioner for further support or care. This could be at the end investigation, but there were also referrals While the section on ‘patient pathways’ of a course of osteopathic treatment or to complementary practitioners and (see page 30) looked at routes from the for additional, parallel treatment from exercise specialists (Figure 2.24).83 wider healthcare system into osteopathic another practitioner. treatment, some data is also available on how osteopaths refer patients onward to Figure 2.24 Destinations for UK patients referred onwards by other medical professionals. osteopaths 52 Respondents to the 2004 survey of (Source: Fawkes C, Leach J, Mathias S, Moore A (2010) The Standardised Data Collection Australian osteopaths estimated their Project – Standardised data collection within osteopathic practice in the UK: development referral patterns. Notable referrals and first use of a tool to profile osteopathic care in 2009. London: National Council for outward were to GPs (68.5% ‘occasionally’ Osteopathic Research.) and 19.2% ‘frequently’), masseurs (48.2% If the patient weas refered on, where was the patient referred to? ‘occasionally’ and 19.3% ‘frequently’), naturopaths/herbalists (43.4% ‘occasionally’ Onwards referrals Number of patients in study and 12.0% ‘frequently’), podiatrists (47.5% ‘occasionally’ and 9.8 ‘frequently’) and Their GP for further investigations 88 medical specialists (48.2% ‘occasionally’ Their GP to try arrange other 33 and 5.2% ‘frequently’).81 Another osteopath 13 Survey data in the UK also demonstrate A homeopath 1 how osteopaths interact with medical An accupuncturist 4 physicians and diagnostic services, as well as with other healthcare providers A podiatrist 15 and health-related practitioners. An Alexander Technique teacher 3 Osteopaths made contact with a A physiotherapist 14 patient’s general practitioner during the course of treatment in just over 10% of A counsellor 6 surveyed cases; for 6.4% of patients this A chiropractor 2 was to a request further information A sports massage therapist 12 or investigation or to request other treatment.82 A Pilates trainer 20 Gym/exercise class 6 Hospital consultant 12 For suspected cancer or mestastasis 1 Other 14
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0 Profession demographics
Age distribution Figure 2.25 Age distribution of US osteopathic physicians The osteopathic profession is relatively (Source: American Osteopathic Association)84 ‘youthful’. In the US, for example, 58% of osteopathic physicians are under the age Age range % of 45 (Figure 2.25). <35 26.2% Data on osteopaths from the 2012 OIA 35-44 32.0% survey found that around one-third were 45-54 22.9% below the age of 40. However, national 55-64 18.1% 53 data show there is considerable variation Unknown 0.9% between individual countries. For example, age data covering all UK osteopaths show 35% under the age of 40 (Figure 2.26), Figure 2.26 UK osteopaths by age group whereas Australian osteopaths have a (Source: GOsC registration data, 2013) markedly ‘younger’ profile, with almost two-thirds (63%) of the profession under Age range % 40 (Figure 2.27). <30 9.3% Data for ‘time out of training’ provides 30-39 additional information on how much 25.5% experience practitioners have in their 40-49 33.4% discipline. As expected, this mirrors the 50-59 ‘young’ age profile of the profession. For 23.3% osteopathic physicians in the US, more 60-69 7.3% than 40% of those in active practice 70-79 graduated less than 10 years ago.85 UK 1.1% data provide a similar pattern with 43% 80+ 0.1% of the profession qualifying within the past 10 years.86 In a survey of osteopaths in Quebec, Canada, the profile was even more pronounced, with more than half 26.2% having 10 years’ or less experience.87
35 30 25 20 15 10 5 0 35 30 25 20 15 10 5 0 Figure 2.27 Australian osteopaths by age group Gender split of practitioners (Source: Osteopathy Registrant Data: December 2012, Osteopathy Board of Australia) In the countries for which there is reliable data, the proportion of female Age range % practitioners has increased over recent decades. This is against a background 21-30 25.0% of higher female participation in the 31-40 38.4% general workforce and an increased 41-50 16.9% representation of women in other areas 54 of healthcare, including as doctors. 51-60 11.6%
61-70 6.2% In the US, women now account for more 71-80 1.7% than a third of all osteopathic physicians, compared with 10% in 1985 (Figure 81-90 0.2% 2.28). In the under-35 age group, women outnumber men as a result of the increase in female entrants to osteopathic medical school over the past two decades.
Figure 2.28 Age and gender distribution of US osteopathic physicians (Source: American Osteopathic Association)88
Age range Male Female <35 48.5% 51.5% 35-44 61.3% 38.7% 45-54 69.6%38.4% 30.4% 55-64 80.0% 20.0% Unknown 53.9% 46.1%
40 35 30 25 20 15 10 5 0
40 35 100 30 80 25 20 60 15 10 40 5 0 20
0 However, this trend may now be levelling Figure 2.29 Age and gender distribution of osteopaths off; following a steady increase over the (Source: OIA 2012 survey) past 50 years, more recently there has been gradual decline in the proportion of female students at US osteopathic Age range % of respondents Male Female medical schools, falling from just over 50% in 2006-7 to 46% in 2011-12.89 The 4.8% <30 ‘feminisation’ of osteopathic medicine is 6.8% broadly in line with what has happened 55 at MD medical schools in the US; in 2012 13.6% 90 30-39 48% of students graduating as MDs from 13.1% medical school were female, compared with 23% of the class of 1980.91 14.6% 40-49 14.8% Data from the OIA 2012 survey found that 48.7 % of responding osteopaths 15.0% 50-59 were female and 51.3 % male. As with 8.4% US osteopathic physicians, the osteopathy profession is becoming increasingly ‘female’ 6.9% 60+ as a result of the growing number of 1.8% women entering osteopathic training. Men are now the minority among osteopaths below the age of 30 (Figure 2.29).
National data for osteopaths most The registration data for Australia for the A non-representative survey of 241 commonly show a higher proportion end of 2012 showed 33.6% of osteopaths osteopaths in Quebec, Canada found of female practitioners than in US are female and 35.6% male, but 30.8% two-thirds were female, and one-third osteopathic medicine. In the UK, preferred not to state their gender.93 (In male, while a similar survey of 98 French registration data for 31 March 2013 contrast, the 2004 survey of Australian osteopaths found 35% female and 65% showed almost half (49.6%) of osteopaths Osteopathy Association members in 2004 male.95 were female.92 found 59% female and 41% male.94)
100 15
12 80
9 60
6 40
3 20 0 0 CHAPTER 3 Models of education and regulation
KEY POINTS Regulation l state licensing of osteopathic physicians dates l Recognition, education and regulation of back to 1897 in the US and licensing of osteopaths osteopathic practitioners have developed to 1978 in Australia. Healthcare regulators in differently around the world, influenced by the several other countries have deemed it important specific cultural, economic, legal and political to establish a legal framework for the practice factors of individual countries. of osteopathic healthcare in order to ensure 56 standards for public safety. Education l Osteopathic education programmes exist in l More countries are now recognising and regulating more than 25 countries. Osteopathic physicians osteopathic care. Since 2000 there has been an and osteopaths share a core curriculum and core increase in countries introducing compulsory competencies, but there are significant differences osteopathic practitioner registration and/or between the two professional streams in education, regulation of practice; there are now at least 15 clinical competency, and scopes of practice. countries where osteopathy and/or osteopathic medicine are regulated. l All osteopathic physicians are university graduates holding medical degrees: in the US they study l there is still no statutory regulatory framework osteopathic medicine, which is fully integrated with for osteopathy in the majority of countries where medical schools, but elsewhere most osteopathic osteopaths practise. physicians are MDs with additional osteopathic qualifications. l the permitted scope of practice of an osteopathic physician is set by the relevant country’s licensing l Across much of Europe, Australia and New and regulatory systems for doctors, including any Zealand, the generally accepted norm for training specific requirements for working as a specialist. as an osteopath has become a Master’s level In countries where there is regulation, osteopaths’ qualification. In some countries the equivalent of practice rights will be nationally defined. However, a Bachelor’s degree remains the accepted norm or for osteopaths in countries that do not recognise post-professional training is accepted. or regulate the profession, scope of practice is often less clear cut. l there have been several initiatives to describe minimum standards for osteopathic education l the osteopathic profession is committed to and training, including the WHO Benchmarks for monitoring and maintaining standards of practice Training in Osteopathy in 2010 and, in Europe, the and ethics. In countries with compulsory licensing European Framework for Standards of Osteopathic or registration, osteopathic practitioners are Education and Training (EFSOET), developed by usually required periodically to renew their licence the Forum for Osteopathic Regulation in Europe or registration. In countries where osteopathy is (FORE). not regulated, professional associations usually work to maintain standards and to establish accepted thresholds of entry into the profession. Globally there are two recognised l In most other countries, osteopathic l This, in turn, can drive the professional streams of osteopathic care has usually been introduced development of a statutory regulatory training and practice, as outlined in by practitioners who have returned structure for the profession as part of Chapter 1. Both models deliver patient- home after training abroad. As the a framework that sets and maintains centred, evidence-informed care number of osteopathic practitioners standards of practice. Regulation incorporating the principles of osteopathic in any country has grown, they comes in various forms, usually shaped philosophy, which includes the use of have often come together to form by wider legal and medical regulatory osteopathic manipulative treatment professional associations. structures that already exist within and viewing the patient using the a country. For instance, regulation 57 biopsychosocial approach. l Similarly, the first osteopathic may be through the protection schools within a country have usually of title (e.g. restrictions on who The training pathways and regulatory been set up by early practitioners, can call themselves an osteopath) structures differ for the two professional initially offering part-time training or through protection of practice streams and also significantly within the in osteopathic philosophy and (e.g. restrictions on who can use training of osteopaths. The overall picture techniques. osteopathic techniques). Often the is complex because within each stream process of introducing regulation can there are also varying models of education l Over time, the training of osteopathic itself force educators and professional and regulation in different countries. practitioners within a country associations to work more closely Recognition, education and regulation of generally becomes more formalised, together. osteopathic practitioners have developed with osteopathic schools achieving in different ways and at different speeds, external quality assurance and l As part of a regulatory structure, influenced by the specific cultural, countries establishing national some countries define specific scopes economic, legal and political factors of academic standards. This has often of practice, either to constrain how individual countries.96 led to university-validated degrees osteopaths can practise (for instance, and postgraduate qualifications in whether they can diagnose) or, less Historically, this development has generally osteopathic care. commonly, to detail what treatments followed a common pattern: practitioners can provide to various l Given a growing number of types of patients (as is currently being l As described in Chapter 1, in the US, practitioners and formalised training introduced in New Zealand, see schools for osteopathic physicians courses, pressure then tends to section on ‘Scope of practice’ page 67). developed in parallel with established build for greater recognition of the medical schools from the late 19th osteopathic profession within the Today, different countries have reached century onwards, and regulation of healthcare and legal systems. different stages in this pattern of evolution. practitioners started as early as 1897. This chapter aims to provide a high- level summary of the models currently utilised by the osteopathic profession worldwide for the training, regulation and maintenance of good practice. Osteopathic education and course accreditation
The OIA 2013 survey demonstrated that osteopathic education programmes exist Box 3.1 Core Competencies of osteopaths and in more than 25 countries (see Chapter osteopathic physicians 2). Although osteopathic physicians and osteopaths share a core curriculum and Osteopathic practitioners share a set of core competencies that guide them in the core competencies (Box 3.1), there are diagnosis, management and treatment of their patients and form the foundation significant differences between the two for the osteopathic approach to healthcare. The following are essential professional streams in education, clinical competencies for osteopathic practice in all training programmes: 97 58 competency, and scope of practice. The educational pathways into the two • A strong foundation in osteopathic history, philosophy, and approach to healthcare. professional streams broadly reflect these • An understanding of the basic sciences within the context of the philosophy of differences, but within each stream there osteopathy and the five models of structure-function. Specifically, this should are also different pathways to qualification. include the role of vascular, neurological, lymphatic and biomechanical factors in the maintenance of normal and adaptive biochemical, cellular and gross anatomical functions in states of health and disease. • An ability to form an appropriate differential diagnosis and treatment plan. • An understanding of the mechanisms of action of manual therapeutic interventions and the biochemical, cellular and gross anatomical response to therapy. • An ability to appraise medical and scientific literature critically and incorporate relevant information into clinical practice. • Competency in the palpatory and clinical skills necessary to diagnose dysfunction in the aforementioned systems and tissues of the body, with an emphasis on osteopathic diagnosis. • Competency in a broad range of skills of osteopathic manipulative treatment. • Proficiency in physical examination and the interpretation of relevant tests and data, including diagnostic imaging and laboratory results. • An understanding of the biomechanics of the human body including, but not limited to, the articular, fascial, muscular and fluid systems of the extremities, spine, head, pelvis, abdomen and torso. • Expertise in the diagnosis and osteopathic manipulative treatment of neuromusculoskeletal disorders. • Thorough knowledge of the indications for, and contraindications to, osteopathic treatment. • A basic knowledge of commonly used traditional medicine and complementary/ alternative medicine techniques.
(World Health Organization (2010) Benchmarks for Training in Osteopathy.) Qualifications of an graduates can pursue specialty training in medical degree. However, a new osteopathic physician any residency programme, regardless of course was due to commence in 2013 whether it is accredited by the American at Novgorod State University that will All osteopathic physicians are university Osteopathic Association, the Accreditation issue a double degree in medicine and graduates holding medical degrees. Council for Graduate Medical Education osteopathy. (which is responsible for post-MD medical United States training programmes) or dually-accredited. In the US over the past century, schools Qualifications of an of osteopathic medicine have developed Europe osteopath 59 in parallel with medical schools that offer In several European countries (such The emerging educational model for a Doctor of Medicine (MD) qualification. as the UK, France, Germany, Austria, osteopaths is a Master’s degree, whether The educational model for osteopathic Belgium and Switzerland), the educational or not preceded by a separate Bachelor’s physicians is a postgraduate doctoral pathway to recognition as an osteopathic qualification. degree, leading to licensure as a Doctor physician is through a first qualification as of Osteopathic Medicine (DO). There a MD, followed by additional osteopathic Students of osteopathy receive advanced are currently 29 osteopathic medical training. In the UK, for instance, registered training in detailed examination schools that will be operating at 37 sites medical practitioners wishing to practise and diagnosis of body structure across 28 states during the 2013-14 osteopathy can take a specially designed and biomechanics. At a minimum, academic year.98 The National Board of recognised study programme to achieve they study anatomy, physiology, Osteopathic Medical Examiners oversees qualification as an osteopath. These pathology, orthopaedics, radiology, the exam, called COMLEX-USA.99 DO types of ‘conversion’ programmes are differential diagnosis and interpersonal students can also sit for the United States considerably shorter than osteopathy communication, plus intensive training Medical Licensing Examination (run by the courses for individuals with no prior in Osteopathic Manipulative Treatment National Board of Medical Examiners), healthcare education. The European (OMT). which is the MD counterpart exam.100 Register for Osteopathic Physicians, for Following successful completion of the instance, requires MDs to attend an DO degree, graduates follow a structured osteopathic training programme of at University-validated courses programme of postgraduate training, least 700 hours over a minimum period Practice as an osteopath now requires during which they can opt to specialise in of 4 years.101 In Europe, osteopathic a relevant university degree in all of any area of medicine (including surgery). physicians commonly hold two separate the countries in which it is regulated by Osteopathic physicians then go on to 102 qualifications, first a MD and then law, although not all these countries practise in their chosen area in a manner a further osteopathy diploma or offer degree courses (for instance South that incorporates osteopathic principles. postgraduate degree. Africa regulates the profession but currently does not offer training courses). Training as an osteopathic physician In Russia, to date, all osteopathic Similarly, in some of the countries that do includes comparable hospital rotations and practitioners are osteopathic physicians offer degree courses, osteopathy is still internships to those that are undertaken who have completed postgraduate unregulated. by MD graduates. Specifically, DO osteopathic training following an MD In the OIA’s 2012 survey of the profession, significant clinical component. Three l Brazil: private colleges offer a majority of osteopaths were university universities offer courses. postgraduate training, based on the graduates, increasingly at Master’s level WHO’s Benchmarks for Training in (see Chapter 2). l New Zealand: entry level to practise Osteopathy, available to graduates as an osteopath is a Bachelor of with a prior health science degree. Various university-validated degrees in Applied Science plus a Master’s degree osteopathy are available, for example in in osteopathy, typically requiring l Croatia: there is one school the UK, Australia, New Zealand, France, five years’ full-time study, including of osteopathy, the Akademija 60 and Switzerland, for students with no a significant clinical component. Osteopatije, but no legal recognition prior healthcare education. In addition, Osteopathy is taught at one institute of osteopathy and (as of May 2013) several countries (such as Austria of technology. no legal recognition of osteopathic and the UK) offer university-validated education by the Ministry of postgraduate courses where graduate l United Kingdom: osteopathic Education. professionals from other non-physician students in the UK follow a healthcare backgrounds, particularly four or five-year degree course l Belgium: there are degree courses those with a prior degree or qualification combining academic and clinical in the Walloon region that are not in physiotherapy, can undertake work, with training available at 11 accredited or quality assured (and postgraduate training which qualifies them osteopathic educational institutions some of these are not recognised in to practise as osteopaths. (including three public universities). the Flanders region of the country).104 Qualifications include a Bachelor’s University osteopathic courses are either degree in osteopathy – BSc (Hons), l Austria: there are a number of basic delivered within state-funded universities BOst or BOstMed – but the standard and advanced training courses but no or institutes of technology, or by specialist nowadays is a Master’s degree in state ‘regimentation’.105 Only certain independent colleges that receive quality osteopathy (MOst). courses are accepted for membership assurance from a validating university.103 of the osteopathy lobby group, the Over the past decade there has been l Switzerland: since 2007, osteopaths Österreichische Gesellschaft für a significant increase in the number of must qualify for the Inter-Cantonal Osteopathie (OEGO). universities and colleges offering or Osteopathy Diploma which requires validating osteopathy training. 5 years of full-time study, commonly Trends in osteopathic education to Master’s level, and a 2-year full-time There has been a large increase in Examples of countries with university- internship. the number of osteopathy schools in validated osteopathic education models recent years, with a growing proportion include: of students enrolled on university- Non-validated courses validated courses. This ‘mainstreaming’ In several countries where osteopathy of osteopathic education has raised and l Australia: entry level to practise as is not yet regulated, private schools and formalised the level of entry qualification an osteopath is a Bachelor of Applied colleges offer courses and postgraduate into the profession in many countries. Science plus a Master’s degree in training programmes. Some examples are: For example, in Australia a five-year osteopathy, typically requiring five training programme has been in place years’ full-time study, including a for over 20 years. In the UK, while prior to statutory In Europe there have also been various mission, goals, and objectives; governance, regulation most registered osteopaths moves to set common standards for administration and finance; facilities, held a diploma level qualification in osteopathic education against the equipment, and resources; faculty; student osteopathy, now the majority of new background of the 1999 Declaration admissions, performance and evaluation; entrants have university validated Master’s of Bologna on harmonisation of higher preclinical and clinical curriculum; and degrees. Across Europe and in Australia education qualifications across member research and scholarly activity.109 The AOA and New Zealand, the generally accepted states and the European Qualifications is also the only accrediting agency for norm for osteopathic training has become Framework, each of which require osteopathic graduate medical education, a Master’s level qualification. equivalence to be recognised. The and must approve all postdoctoral training 61 Forum for Osteopathic Regulation in programmes.* Europe (FORE) has developed a series of voluntary standards, of which the In most countries where osteopathy European Framework for Standards Standardisation and is a regulated profession, a national of Osteopathic Education and Training accreditation in osteopathic system of accreditation is in place, with (EFSOET)108 specifically relates to education the professional regulator working education. EFSOET sets out the threshold There are a number of initiatives to alongside existing institutional and standards necessary for graduates in standardise osteopathic education and national educational quality assurance osteopathic practice. This framework training. mechanisms. In the UK, for instance, the has also been ratified by the European General Osteopathic Council (GOsC) Federation of Osteopaths (EFO). In 2010, the WHO published its scrutinises all courses to ensure standards Benchmarks for Training in Osteopathy, of education and training are maintained, Currently, accreditation of osteopathic one of a series of publications on working closely with the independent educational courses takes place at a selected types of Traditional Medicine Quality Assurance Agency for Higher national level. and Complementary and Alternative Education (QAA). In Australasia, the Medicine. The benchmarks aimed Australian and New Zealand Osteopathic In the US, the American Osteopathic to reflect “what the community of Council (ANZOC) is the delegated Association’s (AOA) Commission on practitioners in each of these disciplines accreditation authority under law. Osteopathic College Accreditation considers to be reasonable practice (COCA) is the professional education in training professionals to practise In countries without regulation for accreditation authority as deemed by the respective discipline, considering osteopathy, educational training the US Department of Education, and consumer protection and patient safety institutions can seek validation for degree accredits all medical schools granting the as core to professional practice”.106 They courses through universities. Doctor of Osteopathic Medicine (DO) were designed to help implement an degree. Accreditation signifies that a earlier WHO resolution which in 2009 college or school of osteopathic medicine had urged Member States “to assist … has met or exceeded the AOA standards practitioners to upgrade their knowledge * Details of the Osteopathic Postdoctoral for educational quality with respect to Training Structure in the US are available at http:// and skill in collaboration with relevant www.osteopathic.org/inside-aoa/accreditation/ 107 health providers”. postdoctoral-training-approval/Documents/ osteopathic-postdoctoral-training-structure.pdf. Recognition, regulation and registration
Licensing of osteopathic physicians dates Recognition and regulation Osteopathic physicians trained in back to 1897 in the US and licensing of of osteopathic physicians Europe are qualified doctors (MDs) with osteopaths to 1978 in Australia. More postgraduate training and education in The practice of osteopathic medicine is recently, healthcare regulators in many osteopathic medicine. Governmental regulated in the US at the state level. All other countries have deemed it important regulatory systems for osteopathic osteopathic physicians must be licensed to establish a legal framework for the physicians exist only in the UK and by the state licensing board in order to practice of osteopathic healthcare in France; in all other countries regulation practise in that state. Those boards may order to set standards and safeguard and licensure as physicians is part of the be combined (DO and MD) or separate, patients. Since 2000 there has been an general medical councils.112 In most 62 depending on the state. US-trained increase in the number of countries EU countries these medical councils osteopathic physicians are licensed to introducing compulsory osteopathic recognise that MDs with postgraduate practise the unlimited scope of medicine, practitioner registration and/or regulation qualifications in osteopathy practise which includes prescribing all controlled of practice. Information held by the OIA osteopathic medicine as a branch of substances as designated by the US and data collected in the OIA 2013 survey complementary medicine. Drug Enforcement Administration in its suggests that there are now at least 15 relevant schedules. countries where osteopathy and/or osteopathic medicine are regulated. In Canada, each Province or Territory governs the registration of medical Currently, various regulatory professionals. Regulation and registration arrangements exist, shaped by each is carried out by the provincial College country’s wider legal and medical of Physicians and Surgeons and only regulatory frameworks. The profession graduates of accredited American colleges may be recognised and regulated; of osteopathic medicine (DO) are eligible recognised but not regulated; or to register as osteopathic physicians. unrecognised. As mentioned in Chapter 1, There is a national standard of medical the countries in which osteopathic practice that allows for reciprocity practice is regulated have implemented among the provinces and territories.110 In legislation in different ways, for example Alberta, British Columbia and Ontario, through protection of title or protection only a registered DO is entitled to use of practice. Osteopathic healthcare the designations ‘osteopath’, ‘osteopathic manages to function well within very physician’ or DO. However, in some states, different types of legal environments. such as Nova Scotia, legislation states that ‘no person’ shall use the title ‘Doctor of Osteopathy’ or ‘Osteopathic Physician’.111 Recognition and regulation Examples of the legislative models for l New Zealand: the osteopathic of osteopaths osteopathy are: profession is regulated under the Health Practitioners Competence The variation in national legal constraints l United Kingdom: osteopathy is a Assurance Act (2003),115 which and freedoms for the osteopathic primary contact profession regulated provides a consistent regulatory profession has meant that many different by the Osteopaths Act 1993.113 UK framework for 16 different healthcare models of recognition and regulation have standards of osteopathic training professions. The Osteopathic Council had to evolve across different countries. and practice are set, maintained of New Zealand is the statutory This report uses four categories to and developed by the profession’s regulator. describe these approaches: 63 statutory regulator, the General Osteopathic Council (GOsC),114 l France: since 2002 osteopathy has l Statutory recognition, regulation and which holds the Register. The title been a recognised profession, and registration. ‘Osteopath’ is protected by law, and from 2007 the title ‘Ostéopathe’ only those included on the Register became protected in legislation.116 l Recognised without regulation. are entitled to practise as osteopaths; Currently there is no single regulatory unregistered practice is a criminal body for osteopathy in France. Instead l Unrecognised and unregulated, but offence in the UK. individual osteopaths have to register free to practise. to practise with their local ARS l Australia: state-based regulation was (Agence Régionale de Santé). l Practice limited to physicians. introduced in 1978, however since July 2010 a National Registration l Finland: the Decree on Healthcare Statutory recognition, regulation and and Accreditation Scheme for health Professionals (564/1994) protects registration professions has regulated osteopathy the title ‘Osteopat’. Practitioners Osteopathy is regulated by law in a as a primary contact profession under entitled to use the professional title growing number of countries including the Health Practitioner Regulation are entered onto the central Register the UK, Australia, New Zealand, France, National Law Act. The Australian of healthcare professionals maintained Finland, Malta, Switzerland, Iceland and Health Practitioner Regulation by the National Supervisory Authority South Africa. Only individuals registered Agency (AHPRA) administers this for Welfare and Health.117 with the relevant authority may use the Act in order to regulate the 14 title ‘osteopath’ and/or practise osteopathy registered health professions. The in these countries. Most countries have Osteopathy Board of Australia (OBA) a single regulatory body, but there are is the statutory body charged with exceptions (e.g. France). Eligibility for granting registration to practise as an registration commonly includes minimum osteopath. training and qualification requirements, professional indemnity insurance, sound physical and mental health and good character. l Malta: osteopathy is a distinct l South Africa: since 1984, osteopaths Examples of the countries that recognise profession, regulated by the Council have been regulated by the Allied but do not yet regulate osteopathy for Professions Complementary to Health Professions Council under include: Medicine that covers a number of the Allied Health Professions Act professions including physiotherapy 1982. The Council administers the l Belgium: the federal government and chiropractic. This body was set registration of osteopaths. is putting forward proposals to up to safeguard the health and well- regulate osteopathy (along with being of the public, by setting and Recognised without regulation other disciplines) – a process which 64 maintaining standards of professional Osteopathy is formally recognised but began when legislation was passed training, performance and conduct. remains unregulated in a number of in 1999 but never implemented. A countries. For example, Belgium and Government appointed Chamber l Switzerland: although many cantons Italy have passed, but not implemented, and a Joint Commission made up had already recognised its practice of legislation; Germany and Portugal have of osteopaths and academics have osteopathy, on 1 January 2007 the recognition and are considering regulation; met on a number of occasions to Swiss Conference of the Cantonal while Brazil and Russia have recognition discuss the definition of osteopathy, Ministers of Public Health (GDK) but are not currently regulating. Where whether it should be a distinct published directives to the cantons regulation does not exist, it is common primary healthcare profession, and on the regulation of osteopathy and for professional associations to maintain what competency profile and level set up a list of requirements to qualify a voluntary register of practitioners and of education should be specified. An for the Inter-Cantonal Osteopathy to set standards of practice and training agreement on regulating osteopathy is Diploma. The cantonal Health or to establish an independent register. expected to be reached in 2013. Ministries each hold a register of Such arrangements have no legal backing practising osteopaths who have passed and are usually viewed as a temporary l Italy: osteopathy has recently been the examination and are therefore measure. The holders of informal recognised as a profession, but not entitled to be called ‘Ostéopathe/ registers are usually engaged with local part of healthcare, following the Osteopath/Osteopata’. governments in pursuit of legal regulation passing of legislation in December to ensure public safety. 2012. l Iceland: the osteopathic profession is a recognised health profession set out l Portugal: osteopathy is a recognised in regulation 1131/2012, regulated profession. It is not yet regulated but by the Icelandic Ministry of Health. the Government has established a No one can work or call themselves health commission which is proposing an osteopath (‘osteópata’) in Iceland a law to regulate osteopathy (along without being registered as such with with other disciplines) which the Ministry was approved by the Portuguese of Health. parliament in summer 2013. l Brazil: the profession ‘Osteopath’ Unrecognised as a profession and l Ireland: there is no statutory was included in the Brazilian unregulated, but free to practise recognition for osteopathy in Ireland. Classification of Occupation from There are many other countries where The Osteopathic Council of Ireland is the Ministry of Labour in 31 March osteopathy is not formally recognised as a limited company operating voluntary 2012. A list of core competencies, a profession, but where osteopaths are regulation of its registrants through activities and skill levels related to the able to practise. These include Denmark, its byelaws. Membership is available osteopathic profession was developed the Netherlands, Sweden, Ireland, Austria, to those who fulfil the required and published in the Classification Cyprus, Spain, Greece, Croatia, Cyprus, standards. The Council is lobbying for document. As a result, from 2013 Israel and Japan, among others. Again, statutory regulation. 65 osteopathy has been acknowledged in these jurisdictions the professional as an occupation in the Brazilian associations may operate voluntary l Canada: osteopathy is currently labour market. registration lists and attempt to establish an unrecognised and unregulated standards of training and practice but profession in Canada. The non- In Greece there is no regulation but these are voluntary and have no legal physician manual practice of in 2011 the outcomes of several legal backing. osteopathy is present in most proceedings led to four individuals provinces, but the title ‘osteopath’ withdrawing from calling themselves In some countries, there is no statutory cannot be used by non-physicians osteopaths while not having any relevant recognition but there are early moves in three provinces (Alberta, certification. In this regard, a form of ‘soft towards regulation. For example: British Columbia and Ontario), so law precedent’ has been established.118 other terms such as ‘osteopathic l Norway: osteopathy is not currently manual therapist’ and ‘osteopathic recognised or regulated so anyone practitioner’ are employed. The may call themselves an osteopath and Canadian Federation of Osteopaths practise as such.119 The profession is represents five provincial associations applying for ‘authorisation’ which is the and is seeking to establish the manual first step towards regulation. A major practice of osteopathy as a regulated step forward has been the approval of profession. Osteopaths in Quebec are the Nordic Academy of Osteopathy able to use the title osteopath freely; (Nordisk Akademi for Osteopati) by the province of Quebec, with over NOKUT – the Norwegian Agency for 1,000 practising osteopaths, is engaged Quality Assurance in Education. with the provincial association in the process of regulation. The province of Nova Scotia is also currently working towards regulation. l Germany: osteopaths work under the Establishing common The Frameworks are currently being used legal framework for ‘Heilpraktiker’, practice standards in Europe to inform the development of a European an umbrella Complementary and Within the European osteopathic Committee for Standardisation (Comité Alternative Medicine profession community, there are moves to agree Européen de Normalisation (CEN)) recognised by the Government and common practice standards. European Standard on Osteopathic covering several practice disciplines. Healthcare Provision. While this would Germany is currently in the process of Osteopathic physicians in five European also be a voluntary standard, it will establishing more specific regulations countries collaborate to promote have greater weight than the existing 66 and standards. and maintain voluntary standards of frameworks and will provide a benchmark osteopathic practice under the umbrella for patients and the public on the Practice limited to physicians of the European Register for Osteopathic minimum standards of osteopathic care In some countries, for example Bulgaria Physicians (EROP). Maintenance of they should expect in those European and the Baltic countries (Latvia, Lithuania the declared core competencies and countries currently without any regulatory 120 and Estonia), the use of osteopathic osteopathic practice standards plays mechanisms for osteopathy. techniques is reserved for medical a central role in the requirements for doctors, even though (unlike the US) osteopathic training and the achievement there is no tradition of osteopathic and retention of registration in EROP.121 physicians. For osteopaths, the Forum for Osteopathic Regulation in Europe (FORE) has developed and published the European Framework for Standards of Osteopathic Practice (EFSOP) and the European Framework for Codes of Osteopathic Practice (EFCOP), in addition to its voluntary standards on education and training in osteopathy mentioned earlier (see section on ‘standardisation and accreditation’, page 61).122, 123 These frameworks have been ratified by the European Federation of Osteopaths (EFO). They have no legal basis and are not designed to override national laws, but have been developed to create an agreed standard of practice in Europe and to help the osteopathic profession achieve recognition and regulation where this does not currently exist. Scope of practice
Scope of practice defines the procedures Some countries also use osteopathy- l The general osteopathic scope of and treatments that an osteopathic specific scopes of practice to define what practice, covering all registered practitioner is permitted to carry out osteopaths cannot do. For example, osteopaths. This scope provides a high under a country’s relevant laws and specific restrictions apply to osteopaths in level definition of what an osteopath is regulations. France, including not being permitted to and does, and endorses a formulation carry out internal or obstetric treatment. of osteopathic principles. The permitted scope of practice of an In additional, for high velocity thrust osteopathic physician is set by the relevant (HVT) manipulation of the cervical spine l Extended scopes of practice, which or HVT manipulation of infants under country’s licensing and regulatory system permit holders of the general 67 for medical doctors, including any specific six months, French osteopaths need a osteopathic scope of practice to requirements for working as a specialist. certificate of ‘non-contraindication’ from extend their clinical practice through a medical practitioner before treatment in additional qualifications. Currently For osteopaths, scope of practice is such cases.124 one extended scope of practice has often less clear cut, especially in countries been developed, for Western Medical that do not recognise or regulate the In some jurisdictions scope of practice Acupuncture and Related Needling profession. Even in those jurisdictions that means that osteopaths are only permitted Techniques. do recognise and/or regulate osteopathy, to practise on patients who have been scope of practice – in terms of what referred by a doctor. In Iceland, for l Vocational scopes of practice have an osteopath can and cannot do – is instance, currently patients seeking been introduced to allow members often not explicitly defined, although care from osteopaths, and other health of the public and referring healthcare to some extent it may be implicit in the professionals, should do so in consultation professionals to identify osteopaths on competencies defined within degree with a doctor; however, this is commonly the Register “with advanced standing programmes. ‘overlooked’ and representations are being in a sub-domain of practice”. Currently made to the Government to change this vocational scopes of practice exist for The scopes of practice of other medical requirement. Gerontology and Pain Management. professions already mean that non- physician osteopaths (like anyone else) are The New Zealand approach to scope of not permitted to carry out activities for practice which, for example, a physician’s licence or One country taking an innovative midwifery qualification are necessary. So, approach to scope of practice is New as mentioned previously, osteopaths are Zealand, where the Osteopathic Council not permitted to prescribe medications, of New Zealand (OCNZ) has started to perform surgery or provide obstetric care. introduce scopes of practice that define specialist areas of practice or particular groups of practitioners. As of January 2013, the main scopes are:125 Maintaining standards and fitness to practise
Monitoring standards of practice have mandatory powers beyond maintain certification and requires The osteopathic profession is committed removing an individual’s membership individuals to complete a minimum to monitoring and maintaining of the association. They can report number of hours of continuing medical standards of practice and ethics, but the an osteopath to a statutory body (for education per 3-year cycle. The individual organisations involved in doing this, and instance, the police), but they cannot Boards make their own timeline for the bodies that can impose sanctions, vary stop an osteopath from practising. recertification, ranging from 6 to 10 years. depending on the statutory environment in each country. Continuing requirements for licensing or Among countries where osteopathy is registration regulated: 68 l In the US, the State Medical Boards In countries with compulsory licensing l Australia: maintaining registration as are responsible for the licensing or registration, osteopathic practitioners an osteopath with the Osteopathy of osteopathic physicians and can are usually required periodically to renew Board of Australia requires annual remove an individual’s licence if there their licence or registration. This provides compliance, including compulsory is cause, such as poor practice or a regular mechanism for monitoring and continuing professional development breach of ethics. Lesser sanctions maintaining standards. (CPD), recent practice and (such as requiring additional training) appropriate insurances.127 can be imposed at various other levels In the US, for example, certification is depending on the findings. not a requirement to practise a medical l New Zealand: in order to continue specialty, but it demonstrates that an to practise, all registered osteopaths l Elsewhere, in countries that regulate osteopathic physician has met the must renew their Annual Practising osteopathy, the national regulator requirements of one (or more) of the Certificate (APC). Among the can set standards or conditions (for 18 AOA Specialty Certifying Boards of requirements is a CPD form instance, requirements for continuous the American Osteopathic Bureau of summarising the CPD activities and professional development) for Osteopathic Specialists.126 Since 1939, credits achieved during the previous continued licensing or registration. the American Osteopathic Association calendar year. An APC may be Ultimately, where fitness to practise has maintained a programme of board investigated by or have conditions issues are proved, the regulator has certification for physicians who complete placed upon it by the regulator, the the power to remove a practitioner residency training in programmes Osteopathic Council of New Zealand, from the Register which means they approved by the AOA. At present, the if an osteopath has failed to maintain can no longer legally practice. AOA certifies osteopathic physicians in the required standard of competence specialties ranging from family medicine or has not complied with APC l In unregulated countries, codes of and paediatrics to neuropsychiatry, renewal conditions.128 practice and continuing professional through these 18 specialty certifying development requirements may Boards. AOA Board certification is be set by professional associations, based upon completion of approved which may also maintain a register graduate medical education and passage of practitioners. However, these of a psychometrically-valid rigorous arrangements are voluntary, and examination process. Recertification the professional associations do not is mandatory for those who want to l UK: the General Osteopathic In countries where osteopathy is not l Spain: the Spanish Register of Council’s (GOsC) Osteopathic regulated, it is the professional associations Osteopaths (Registro de los Practice Standards comprise both or voluntary registers that usually work Osteópatas de España) is a non-profit the Standard of Proficiency and the towards maintaining standards and organisation that attempts to group Code of Practice for osteopaths.129 establishing accepted thresholds of together those osteopaths in Spain Maintaining these standards is entry into the profession – with only ”who, according to their academic necessary for the retention of rare examples of mandatory rather level, are up to the European registration. Separately, and in line than voluntary systems. Some examples standards established by the European 133 with all UK healthcare regulators, include: Federation of Osteopaths”. 69 the GOsC is currently developing a scheme for regular ‘revalidation’ which l Ireland: with no statutory recognition l Austria: the Österreichische will require all registered osteopaths of osteopathy, the Osteopathic Gesellschaft für Osteopathie (OEGO) periodically to demonstrate that they Council of Ireland is a professional is the lobby group of Austrian are up to date and fit to practise, association set up as a limited osteopaths. It is campaigning for and meet the relevant professional company to operate a voluntary the accreditation of osteopathy in standards. register and work for high clinical and order to achieve common regulated professional standards until regulation standards for osteopathic training and l South Africa: the regulator, the Allied is introduced.132 While it lacks practice of the osteopathic profession; Health Professions Council, has set statutory powers, it seeks to govern, its members must have received guidelines which require registered regulate and represent the profession, training accredited by the OEGO.134 osteopaths (and other healthcare and for continuing membership professionals) from July 2013 osteopaths are expected to commit to onwards to maintain a CPD Activity continuous learning and professional Record and to accrue the necessary development and subscribe to a code Continuing Education Units every two of practice in line with standards years.130 set by the Forum for Osteopathic Regulation in Europe (FORE). l France: continuing professional development is now mandatory but l Netherlands: with no statutory has not yet been enforced.131 regulation, the Dutch Register (Nederlands Register) was created following a split from the professional association (Nederlands Vereniging voor Osteopathie) to act as the ‘regulator’. As part of this, members of the Register have to fulfil 160 hours continuing professional development over five years. Inter-country recognition of osteopathic qualifications
The professional right to practise as In the UK, for instance, if a US DO wants In other countries, the situation for an osteopathic physician or osteopath to work as a doctor and use the word overseas-trained osteopaths depends, outside the country of qualification may osteopath in their title, they must register firstly, on whether a regulatory or be restricted by the destination country. with both the General Medical Council registration system exists at all in the and the General Osteopathic Council destination country; if osteopathy is US-trained osteopathic physicians are (GOsC); but if they refer to themselves not regulated then overseas-trained currently able to practise with unlimited only as a general practitioner or specialist osteopaths may practise, subject to other practice rights in approximately 60 they do not have to register with the laws relating to healthcare or business GOsC. Similarly, in Australia US-registered activities that are relevant. 70 countries, and in a number of other countries with restricted rights, subject osteopathic physicians may register with to completing the necessary licensing or the Medical Board of Australia in order to If osteopaths are regulated in the registration requirements for the specific practise medicine, but must also register destination country, then the right of an country. For example, some countries with the Osteopathy Board of Australia to overseas-qualified osteopath to practise only recognise the osteopath aspect of practise as an osteopath. will depend on whether their education the osteopathic physician’s training and qualifications and experience are only allow US DOs to practise osteopathic From the reverse perspective, only accepted as meeting local requirements. manipulative techniques, rather than the graduates of US colleges of osteopathic In the UK, for instance, the qualifications full scope of medicine. medicine are permitted to practise in and experience of overseas-trained the US as osteopathic physicians. As the osteopaths will be assessed and further While a physician’s licence is mandatory, non-physician profession of osteopath evidence of the level of practice may the requirement for an osteopathic is not recognised in the US, osteopaths be required, for example through an physician to be separately licensed or who have trained outside the US cannot Assessment of Clinical Performance. Only registered to work as an osteopath varies practise as, or call themselves, osteopaths those foreign-trained osteopaths who between countries, as outlined above. in America. As mentioned earlier, they are meet the requirements for UK registration only allowed to call themselves massage are permitted to practise in the UK. therapists and can only practise in the state where they are registered as such. Globally, automatic cross-border Ahead of the consultation, a report recognition of osteopathy qualifications for the Australian and New Zealand is at an early stage in regulated countries. Osteopathic Council (ANZOC) had Osteopaths registered to practise in judged that graduates of UK-accredited Australia may also practise in New osteopathy training programmes since Zealand and vice versa under the terms 2000 had reached equivalent standards of the Trans-Tasman Mutual Recognition to their Australian and New Zealand Agreement (TTMRA). counterparts except with regard to the socio-cultural, structural and medico-legal 71 In 2010 a Memorandum of Understanding aspects of Australian healthcare delivery was signed by the Osteopathy Board of and financing – which it said could be Australia, the Osteopathic Council of addressed in a specially developed module New Zealand (OCNZ) and the General for all internationally qualified osteopaths Osteopathic Council of the United seeking registration in Australia.136 Kingdom, with the commitment that the regulators would work together to agree comparable arrangements for registering osteopaths from all three countries.135
The OCNZ opened two routes to registration for UK-trained osteopaths in April 2011, and in early 2013 the Osteopathy Board of Australia carried out a consultation on a draft framework on pathways for registration of overseas- trained osteopaths. CHAPTER 4 Efficacy, safety and cost- effectiveness
KEY POINTS
l A body of evidence on manual techniques exists, in the form of systematic reviews and randomised controlled trials, showing the effectiveness of manual therapy using manipulation for low back pain.
l In Australia, Europe, New Zealand and the US, clinical guidelines for 72 the treatment of low back pain recommend osteopathic techniques such as spinal manipulation.
l Robust scientific research into the efficacy of other osteopathic techniques has been limited, and in many areas remains inconclusive.
l the osteopathic profession is committed to evidence-based practice and over the past decade there has been an expansion in research activity on the outcomes and efficacy of techniques used by osteopathic practitioners. Osteopathic healthcare has been used Pragmatic trials are a common approach This research into techniques nevertheless safely and effectively in a growing number in osteopathic research; these are trials provides very relevant and useful evidence of countries around the world, with designed to evaluate the effectiveness of that has also been used to provide clinical benefits to patients and a relatively low interventions in real-life routine practice guidance for national health systems. risk of harm. This chapter reviews the conditions and allow for some variation in available research, and points to sources of clinical delivery to reflect practice. Finally, it should be noted that inconclusive further information. (or non-existent) evidence does not The osteopathic profession is committed equate to negative evidence. Nor should to evidence-based practice and over the any historic shortcomings in the design of To date, robust scientific research into 73 the efficacy of osteopathic techniques has past decade there has been an expansion the available research studies reflect on been limited, and in many areas remains in research activity. A body of evidence the osteopathic techniques themselves. inconclusive. Osteopathic healthcare, does now exist and, looking ahead, like a number of other medical and an increasing number of osteopathic psychotherapy interventions, does not practitioners are involved in research lend itself to the ‘gold standard’ of double- that is carried out to standards that blinded randomised controlled trials are recognised across the healthcare (RCTs) used in pharmaceutical research. professions.
RCTs are where patients are randomly Some forms of manual techniques, such allocated to either the ‘intervention’ as spinal manipulation, are used by other arm (the treatment under investigation) professions as well as osteopaths. As a or a ‘control’ arm which can be usual result, much of the currently available care, nothing (sometimes in the form of research has investigated the outcomes of placebo) or a comparative treatment. specific treatment techniques, regardless Placebos are difficult to implement as of the type of healthcare professional patients know when they are being (osteopath, osteopathic physician, touched, and even “sham” therapies have chiropractor, manual therapist) delivering a mechanical input, thus making blinding the treatment. Thus the evidence difficult (in a similar way, it is difficult to reviewed below covers manual therapies “fake” surgery). and techniques of the type used by osteopathic practitioners, rather than the practices of osteopathic physicians or osteopaths per se. Clinical guidelines on low back pain
Guidelines are recommendations to In England, the Department of In the US, the American College of health professionals on the appropriate Health’s 2006 guidance to the NHS Physicians and the American Pain treatment and care of people with specific on musculoskeletal services includes Society in 2007 published a joint clinical diseases and conditions. The guidance is developing capacity in primary care by practice guideline on the diagnosis and based on the best available evidence on offering a wider range of non-surgical treatment of low back pain. Among its a treatment’s efficacy and, increasingly, its alternatives (including osteopathy), and recommendations was that, for patients cost-effectiveness. a role for osteopaths in multidisciplinary who do not improve with self-care Clinical Assessment and Treatment options, clinicians should consider the 140 74 Osteopathic techniques have been Services. More recently, the National addition of non-pharmacologic therapy mentioned in clinical guidelines for Institute for Health and Clinical Excellence with proven benefits for acute low back almost 20 years, mostly in relation to (NICE) in 2009 issued guidance on the pain, specifically spinal manipulation; for the treatment of patients with low back early management of persistent non- chronic or sub-acute low back pain, spinal pain. In the UK, the Clinical Standards specific low back pain.141 It covers people manipulation was also included in a list of Advisory Group (CSAG) produced clinical who have been in pain longer than six therapies that should be considered.143 guidelines for the management of acute weeks but less than one year, where low back pain in 1994; manipulation was the pain may be linked to structures in recommended “within the first six weeks the back such as the joints, muscles and of the occurrence of symptoms for ligaments. The recommendations include patients who need additional help with offering a course of up to nine sessions pain relief or who are failing to return to of manual therapy over up to 12 weeks, normal activities”.137 including spinal manipulation, spinal mobilisation and massage, provided by The European back pain guidelines a range of health professionals including covered the treatment of acute and osteopaths. (In contrast, NICE does chronic back pain. The guidelines for not recommend cranial osteopathy for acute non-specific low back pain include the management of otitis media with “consider (referral for) spinal manipulation effusion.142) for patients who are failing to return to normal activities”.138 The 2005 guidelines for chronic low back pain recommend, under the heading ‘conservative treatments’, that “short courses of manipulation/mobilisation can also be considered” for chronic low back pain patients.139 Evidence of the outcomes of osteopathic techniques
The most robust research evidence is The various controls in the studies While some of the review studies covered provided by systematic reviews (studies included: sham ultrasound; placebo/sham acute low back pain, the majority looked that analyse data from several trials to manipulation; no intervention; drugs; at chronic low back pain.145 Overall, the produce a combined result) of RCTs and moist heat; chemonucleolysis; sham findings demonstrated that osteopathic the larger RCTs themselves. This section treatment plus standard care; chiropractic manipulative treatment significantly provides a selection of some of the widely techniques antiphlogistics and cortisone reduced low back pain. The level of pain cited research in the field of osteopathic injections; exercises or manipulative reduction was greater than expected from healthcare. It has drawn heavily on a physiotherapy; manual mobilisation; placebo effects alone, persisted for at least review of the current evidence carried short-wave diathermy and a placebo; and three months, and was found regardless of 75 out in the UK by the National Council standard care. The review found a lack whether trials were performed in the UK for Osteopathic Research (NCOR); an of independently replicated results and or the US. Significant pain reductions were overview of the identified research papers concluded that the available data failed also observed during short-, intermediate-, and links to more detailed information to produce compelling evidence for the and long-term follow up. on the research material are available at effectiveness of osteopathy as a treatment http://www.ncor.org.uk/. of musculoskeletal pain. It recommended In an earlier RCT by the same lead that future studies should be in line with author into chronic nonspecific low accepted standards of trial design and back pain, the subjects were randomised Musculoskeletal pain reporting. to osteopathic manipulative treatment, A systematic review looked at 16 sham manipulation, or a no-intervention RCTs involving the use of osteopathic control group, and they were allowed to manipulation/mobilisation for patients Back pain continue their usual care for low back with any musculoskeletal pain in any The majority of research studies into pain. It had found that, compared with the anatomical location.144 Five of the back pain have looked at the outcomes no-intervention control group, patients RCTs suggested that osteopathy lead of osteopathic treatment for chronic low who received osteopathic manipulative to a significantly stronger reduction back pain. An important systematic review treatment reported greater improvements of musculoskeletal pain, compared to published in 2005 assessed the efficacy in back pain, greater satisfaction with various control interventions. Eleven RCTs of osteopathic manipulative treatment in back care throughout the trial, better indicated that osteopathy, compared primary care; unlike many other reviews, physical functioning and mental health to controls, generated no change in eligibility for inclusion was limited to RCTs at one month, and fewer co-treatments musculoskeletal pain. of interventions performed by osteopaths, at six months. However, the subjects osteopathic physicians, or osteopathic who received sham manipulation also trainees that included blinded assessment reported greater improvements in back of low back pain in ambulatory settings. pain and physical functioning and greater satisfaction than the control group. There were no significant benefits with osteopathic manipulative treatment, compared with sham manipulation.146 Most recently, the same lead author Relative to “best care” in general practice A recent systematic review of RCTs into studied the efficacy of osteopathic alone, the addition of manipulation the effectiveness of spinal manipulative manual treatment and ultrasound therapy followed by exercise achieved a moderate therapy (spinal manipulation or for short-term relief of nonspecific benefit at three months and a small mobilisation) in adults with acute low back chronic low back pain. Patients receiving benefit at 12 months; spinal manipulation pain (pain of less than six weeks’ duration, osteopathic manual therapy were more achieved a small to moderate benefit but excluding sciatica) found it no more likely than patients receiving sham therapy at three months and a small benefit effective in participants with acute low to achieve moderate and substantial at 12 months; and exercise achieved a back pain than inert interventions, sham 76 improvements in low back pain at week small benefit at three months but not therapy, or when added to another 12, and also used prescription drugs less 12 months. No significant differences in intervention.152 However, the evaluation frequently. The study found no statistical outcome occurred between manipulation was limited by the small number of studies interaction between osteopathic manual in NHS premises and in private premises, per comparison, outcome, and time treatment and ultrasound therapy, and no serious adverse events occurred. interval; the authors stated that future and that ultrasound therapy was not research was likely to have an important efficacious.147 Individual RCTs investigating the use of impact. The paper concluded that the osteopathic manipulation for sub-acute decision to refer patients for spinal In a review of spinal manipulative therapy pain have indicated positive results. manipulative therapy should be based for patients with chronic low back pain, One study found that the addition of upon costs, preferences of patients and high quality evidence showed a statistically treatment in a primary care osteopathy providers, and the relative safety of the significant, short-term effect on pain clinic improved short-term physical and intervention compared to other treatment relief and functional status, compared longer-term psychological outcomes for options. with other interventions. However, these sub-acute neck or back pain of 2 to 12 findings were not found to be clinically weeks’ duration compared with usual GP An early open-controlled pilot trial of relevant.148 care alone.150 A separate RCT found that patients with nonspecific low back osteopathic manual care and standard pain showed that some participants A large UK RCT (the BEAM trial) involving medical care had similar clinical results presenting with pain durations of 14 1,334 patients with low back pain in patients suffering fromsub-acute low to 28 days responded to osteopathic compared “best care” in general practice back pain for three weeks to six months, manipulative treatment. No response alone with the effect of adding exercise but those receiving manual therapy used was demonstrated in those with shorter classes, spinal manipulation delivered in significantly less medication (analgesics, episodes at presentation, and the NHS or private premises, or manipulation anti-inflammatory agents, and muscle advantage to manipulated patients was followed by exercise. The patients had relaxants) and less physical therapy.151 maximal between one and two weeks experienced pain every day for 28 days after commencing treatment, but was not before randomisation or for 21 out of the discernible after four weeks.153 28 days and 21 out of the 28 days before that. All groups improved over time.149 An RCT investigating the effects of Separately, a systematic review was Effectiveness in treating these types of osteopathic manipulative treatment for carried out of all systematic reviews of headache was comparable to commonly back pain during pregnancy found that the effectiveness of spinal manipulation used first-line prophylactic prescription it slowed or halted the deterioration of for any medical condition, published medications, but spinal manipulative back-specific functioning during the third between 2000 and May 2005. Overall, the therapy did not appear to improve trimester of pregnancy.154 Effects on conclusions of the 16 included reviews outcomes when added to soft-tissue back pain were less conclusive; back pain were largely negative, except for back pain massage for episodic tension-type appeared to decrease when osteopathic where spinal manipulation was considered headache.160 manipulative treatment was combined superior to sham manipulation but not 77 with usual obstetrical care (and remained better than conventional treatments.158 A single-blind, randomised study unchanged or increased in comparator Three systematic reviews on back pain compared the effects of osteopathic groups) but not to the extent that this was and one on lower back pain and neck pain treatment and progressive muscular statistically significant. were included in the review. relaxation exercises on patients with tension-type headache. The results Among other back pain related research is showed that participants who did a systematic review of the clinical efficacy Headache and neck pain relaxation exercises and received three of spinal manipulation in the management There is encouraging, albeit inconclusive, osteopathy treatments had significantly of disc herniation, relative to published evidence that spinal manipulations are more days per week without headache data on harms. The reviewers found some effective in the treatment oftension- than those who did only relaxation evidence, although weak, suggesting that type headaches (pain or discomfort exercises.161 spinal manipulation may be beneficial associated with muscle tightness).159 Four in the early stages of disc herniation. of the five RCTs included in the review For cervicogenic headaches (a common However, more research is needed to aid suggested that spinal manipulations type of headache that originates in the practitioners’ decision-making on benefits were more effective than drug therapy, neck) the therapeutic value of spinal versus harm.155 Another systematic spinal manipulation plus placebo, sham manipulation remains uncertain due to review concluded that massage might spinal manipulation plus amitriptyline (a a lack of rigorous RCTs. However, the be beneficial for patients withsub-acute headache medication) or sham spinal findings from many of the RCTs included and chronic nonspecific low back pain, manipulation plus placebo, usual care or in systematic reviews have been positive. especially when combined with exercises no intervention. An earlier systematic and education;156 and evidence of review also found that spinal manipulative “acceptable reliability” of spinal palpation therapy appeared to have an effect on for diagnosis of back and neck pain, with tension-type headache and migraine pain provocation tests the most reliable headache. and soft tissue paraspinal palpatory diagnostic tests not reliable.157 One review concluded that cervical spinal None of the manual therapies used alone Results relating specifically to manual manipulation techniques may provide or in combination were found to be therapies from the Bone and Joint Decade effective treatment,162 and the majority superior over the others. It was, however, 2000–2010 Task Force on Neck Pain and of RCTs in another systematic review notable that consistently adding exercises Its Associated Disorders found consistent suggested that spinal manipulation was to manual therapy produced greater evidence from four RCTs that active more effective than physical therapy, efficacy.165 The benefit of combining therapies involving mobilisation were gentle massage, drug therapy, or no manual therapy with exercise was also associated with greater pain reduction in intervention (although these studies did identified in another systematic review, the short-term among persons with acute 78 not have adequate controls for placebo which found moderate quality evidence whiplash-associated disorders when effect).163 An earlier systematic review supported manipulation or mobilisation, compared with usual care, soft collars, found spinal manipulation had a better combined with exercise, for pain passive modalities, or general advice.168 effect than massage for cervicogenic reduction and improved quality of life over When looking at the evidence for headache.164 manual therapy alone for chronic neck sub-acute or chronic nonspecific neck pain.166 pain, the results were inconclusive, but Manual therapies are often used, appeared stronger for mobilisation (alone either alone or combined with other A systematic review comparing the or with medication) than for cervical treatment approaches, to treat neck pain effects of manipulation and mobilisation spine manipulation (alone or with advice and the evidence is broadly positive. A found moderate quality evidence showed and home exercises). The task force review of trials covering manipulation, cervical manipulation and mobilisation concluded that therapies involving manual mobilisation and myofascial techniques produced similar effects on neck pain, therapy and exercise were more effective (but not massage or mechanical traction) function and patient satisfaction at than alternative strategies for patients with concluded that manual therapies intermediate-term follow-up. Low quality neck pain. contributed to improved pain and evidence suggested cervical manipulation function in adults with nonspecific neck may provide greater short-term pain relief pain. A moderate level of evidence than a control. Low quality evidence also was found for short-term effects of supported thoracic manipulation for pain thoracic manipulation combined with reduction and increased function in acute electrothermal therapy and short-, pain and immediate pain reduction in medium- and long-term effects of cervical chronic neck pain.167 manipulation. A limited level of evidence was found for chronic neck pain and neck pain of variable duration. Miscellaneous The evidence base for less commonly For many medical conditions that are As Chapter 2 illustrated, patients present treated conditions is often sparse. A less commonly treated by osteopathic for osteopathic treatment with a wide recent systematic review of randomised practitioners, there is insufficient research range of medical conditions. controlled trials, and pre-and post- to form a judgement of the efficacy of designs on manual therapy for chronic osteopathic healthcare. For example, a A study of children aged between six obstructive airways disease found only systematic review found there was not months and six years old with recurrent one small study with a low risk of bias. In enough high quality evidence to support acute otitis media looked at the effects of this study, performance based measures or refute the use of manual therapy for 173 osteopathic manipulative treatment as an of pulmonary function changed minimally patients with bronchial asthma; the 79 adjuvant therapy to routine pediatric care following osteopathic manipulative lack of serious scientific data means no compared with routine paediatric care. techniques, but patient reported measures conclusion can be drawn on the efficacy for ‘improved health’ and ‘breathing of manual therapy as an efficacious Adjusting for baseline frequency of difficulty’ did improve compared to the technique for the treatment of adolescent 170 episodes before entry to the study, control. idiopathic scoliosis (curvature of the 174 patients receiving routine care plus spine); and a qualitative systematic osteopathic manipulative treatment had A recent RCT to investigate the effect review could only find a single trial of fewer episodes of acute otitis media, of osteopathic manipulative treatment osteopathy and fibromyalgia (chronic fewer surgical procedures, and more mean on self-reported pain and quality of widespread pain and a heightened 175 surgery-free months than those only life in an elderly population affected by response to pressure). receiving routine care. Baseline and final osteoporosis found an increased self- tympanograms (graphic representations of reported quality of life that appeared A systematic review of the therapeutic the acoustic impedance and air pressure to be caused by an improvement in effects of cranial osteopathic manipulative of the middle ear) obtained by an psychological factors (i.e mental well- techniques found that positive clinical audiologist showed an increased frequency being and health perception) rather outcomes were reported for pain of more normal tympanogram types than physical factors; the effect on pain reduction, change in autonomic nervous 171 in the intervention group. No adverse perception was less clear. An older RCT system function, and improvement 176 reactions were reported. found a selected osteopathic manipulative of sleeping patterns. However, treatment protocol did not appear to be the currently available evidence was Overall, the results of the study suggested efficacious during hospital rehabilitation insufficient to draw definitive conclusions a potential benefit of osteopathic of patients who had recently undergone and further research was recommended. manipulative treatment as adjuvant surgery for knee or hip osteoarthritis or 172 therapy in children with recurrent acute for a hip fracture. otitis media, and the researchers propose that it may prevent or decrease surgical intervention or antibiotic overuse.169 Another systematic review into the clinical A review of the evidence surrounding A single RCT has looked at the effect of benefits of cranio-sacral therapy found the general use of manipulative therapies osteopathic treatment on the general positive clinical outcomes were reported for infantile colic determined that the health, well-being and physical functioning for pain reduction and improvement methodological quality and size of the of children aged 5 to 12 with cerebral in general well-being of patients.177 studies made it impossible to arrive at a palsy but did not find statistically significant However, the study revealed a ‘paucity’ definitive conclusion; several studies had evidence that osteopathy lead to sustained of research in patients with different a high risk of performance bias (because improvement in motor function, pain, clinical pathologies, while noting that the parents were not blind to whom had sleep or quality of life in the children 180 80 assessment of the technique would received the intervention) but did appear nor in quality of life of their carers. be feasible through RCTs and had the to indicate that the parents of infants However, compared with children in the potential to provide valuable outcomes receiving manipulative therapies reported control group, carers of children receiving to support clinical decision making. An fewer hours crying per day than parents cranial osteopathy were nearly twice as older systematic review also found that whose infants did not.179 Again, further, likely to report that their child’s global effective research methods had not been more rigorous research was suggested. health had ‘improved’ at 6 months rather used, and that weak study design meant than ‘decreased’ or ‘remained the same’. there was no valid scientific evidence of effectiveness.178 Safety of osteopathic practice
A systematic review has explored the In the RCTs, the rate of adverse events Patients were surveyed before treatment, incidence of adverse events of different in the manual therapy trial arms, were one day and two days after treatment severity and relative risk of different similar to those in the control arms. For and at six weeks. Selected patients were manual therapies.181 It found major RCTs comparing manual therapy with interviewed. 1,082 (27.8%) osteopaths adverse events and deaths were rare as pharmaceutical agents, adverse events completed the practitioner survey, a direct consequence of manual therapy; were significantly less likely within manual and 24 osteopaths were interviewed. however, minor adverse events were therapy treatment groups.184 2,057 patients were recruited by 212 common.182 osteopaths; these patients completed Being female and ‘patient‘s first visit’, were questionnaires before their treatment. 81 Using data from prospective cohort likely risk factors for reporting adverse 1,387 (77%) patients returned six week studies and RCTs, mild adverse events events. Risk factors most closely associated follow-up questionnaires. Interviews took post treatment affected around 40–50% with major adverse events, occurring place with 19 patients. of patients. Major adverse events such after manual therapy were unusual neck as death, vascular insults and major pain/stiffness, having an upper cervical Immediate increase in pain/symptom neurological incapacity were “very manipulation, seeing a clinician in the intensity was the most frequent reaction rare”. The reported incidence of major preceding weeks (indicating patient post treatment and occurred in around cerebrovascular insults, incidents or concern about their condition rather than 20% of patients; these treatment reactions accidents following cervical manipulation causality).185 were perceived by patients at interview as ranged from 1: 120,000 to 1: 1,666,666, acceptable.187 (median 1: 1,000,000, excluding extreme The Clinical Risk Osteopathy and outliers). One study reported the Management (CROAM) study researched Four per cent (10) of patients reported incidence of lumbar disc herniations the outcomes of osteopathic manipulation temporary incapacity or disability that they following manipulation as, 1:38,013 lumbar and other treatment reactions.186 The attributed to their osteopathic treatment. manipulations. Incidence for cauda equina CROAM study team surveyed UK Two of these patients described syndrome was reported in two studies, practising osteopaths and followed experiences characteristic of a major data ranged from <1: 3.7 million to up a group of selected osteopaths adverse event at interview. There were no 1:100 million lumbar manipulations. Most using in-depth interviews of selected reports of life-threatening events, referral adverse events occur within 24 hours osteopaths. Osteopaths also invited to hospital or other permanent disability of treatment. Most mild to moderate patients to provide information about in the patient sample.188 adverse events, such as muscle soreness, their experience of osteopathic care and aching and headache resolve within 24 its outcomes. hours.183 Around 12% of osteopaths reported A recent review of RCTs on the use of A review of spinal manipulation in patients experiencing a major adverse manipulation and mobilisation for patients patients with disc herniation found event over the span of their career. Four with neck and low back pain also found evidence for harms was based primarily per cent of osteopaths reported such that reported adverse events were mostly on case reports: incidences appeared events within the past twelve months. The moderate in severity and of transient to be rare, though the authors most conservative estimate of the rate nature (e.g. increased pain).190 cautioned that underreporting may of major adverse events derived from be a significant problem.192 The study these data was 1 in 36,000; however the A systematic review that looked concluded treatment was “likely to be 82 margins of error around this estimate are specifically at the risk of stroke from safe when used by appropriately-trained unknown. The study’s authors concluded neck manipulation found that the practitioners”, but there was an urgent that it was more useful to consider the number and quality of relevant studies need for more research in this area in evidence from the study as suggesting that meant conclusive evidence was lacking order to help practitioners make decisions major events were rare, but do occur and for a strong association between neck on benefit versus harm. that “osteopathy can be considered a low manipulation and stroke, but was also risk intervention”.189 absent for no association.191 Cost-effectiveness of osteopathic practice
There is a paucity of published well- The paper states that in economic terms, For studies that looked at manipulation designed cost-effectiveness studies of “if decision makers value additional QALYs and low back pain, there were varied osteopathic healthcare techniques.193 at much less than £3,800, “best care” results. One found no differences in Robust cost-effectiveness analysis of a in general practice is probably the best costs between manual therapy, general treatment looks at whether the difference strategy. If their valuation lies between practitioner care (rest, sick leave, direct in cost can be justified in terms of how £3,800 and £8,700, spinal manipulation prescription, advice about posture, and much someone’s life can be extended followed by exercise classes (“combined information about nature of the pain), and/or improved by a new treatment, treatment”) is likely to be the best and intensive therapy for acute low back 198 when compared against existing routine treatment. If their valuation is well above pain. In another, costs were higher for 83 treatment. This type of analysis uses the £8,700, manipulation alone is probably the manipulation compared with medical care concept of the QALY (quality-adjusted best treatment”. (analgesics or muscle relaxants) without life year), which is a standard and producing better clinical outcomes for internationally recognised measure of A cost-utility analysis of osteopathy patients with mixed duration of low back the impact of a health technology. Cost- in primary care in the UK looked at a pain.199 As mentioned above, in patients effectiveness is assessed by calculating practice-based osteopathy clinic and with sub-acute and chronic low back pain, how much the treatment costs per QALY patients with sub-acute spinal pain of 2 spinal manipulation in addition to GP care gained and is expressed as, for example, to 12 weeks duration.195, 196 Costs were (recommending active management and £ per QALY. This is used to produce measured from a National Health Service the use of the Back Book) was relatively the incremental cost-effectiveness ratio (NHS) perspective. Osteopathy plus usual cost effective compared to GP care (ICER), which is the ratio of change in GP care was found to be more effective alone.200, 201 In chronic low back pain the costs to incremental benefits of clinically than usual GP care alone, but patients, there were no differences in a therapeutic intervention. In the UK, resulted in more healthcare costs. The costs between physician consultation, the National Institute for Health and point estimate of the incremental cost spinal manipulation plus stabilising Clinical Excellence (NICE) does not set per QALY ratio was £3,560. The author exercises, and physician consultation an ICER ceiling, but approved treatments concluded that a primary care osteopathy alone.202 Results were difficult to compare commonly have an ICER below £30,000 clinic may be a cost-effective addition due to differences in healthcare systems, per additional QALY gained. to usual GP care, but rigorous multi- perspectives, interventions, populations, centre studies were needed to assess the and methods used. The cost-effectiveness analysis carried generalisability of this approach. out as part of the UK BEAM RCT on a An economic evaluation alongside an range physical treatments for low back A recent systematic review and meta- RCT evaluated the cost effectiveness of pain in primary care concluded that spinal analysis that considered the cost- physiotherapy, manual therapy, and care manipulation was a cost effective addition effectiveness of various complementary by a general practitioner for patients to “best care” for back pain in general and alternative treatments for neck and with neck pain. The cost effectiveness practice, and that manipulation alone low back pain found that the evidence ratios and the cost utility ratios showed probably gives better value for money base meant it was not possible to reach that manual therapy (spinal manipulation) than manipulation followed by exercise.194 clear conclusions about the cost- was less costly and more effective than effectiveness of any of the treatments.197 physiotherapy or general practitioner care.203 Development of research
Globally the osteopathic profession has recognised the need for more research and the development of the evidence base for osteopathic healthcare. There is increased collaboration within the profession, nationally and internationally, and with other professions, which will facilitate larger studies with stronger 84 methodological approaches.
In addition, the new paradigms of clinical research and evidence collection may be particularly suited to the evaluation of osteopathic interventions. In all countries with regulation, concerted efforts are being made, particularly with respect to safety monitoring, to observe, assess, and document the efficacy and safety of osteopathic manipulation in order better to inform patients. References
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